Oral surgery sheet # 1 - Wafa'a Iseid

by **Shadi Jarrar** 23/9/2011, 8:56 pm

http://www.mediafire.com/?fu6dm8p3u1rdwue

Introduction: History & Examination

Books:*

1. Contemporary oral and maxillofacial surgery 5^th ed. (2008).

2. Medical problems in dentistry (2004).

General instructions: Doesn't relate to lecture's material but just general instructions for this clinical year.

-The doctor said that sheets are not enough to get high marks in this course & the student who studies only from sheets will lose about 25-30% of his mark, so you have to go back and study from books. The doctor also said that not only the lecturer will create questions in the exam, but also some other doctors would participate in exam questions. The doctor said again that exam questions won't come from the slides but from the book mentioned above, so be careful!

-We have 3 cons & endo sessions every week, so there're no excuses at all not to finish our clinical requirements. We have the right to miss two oral surgery clinics, however; there's no compensation at all except in certain cases and only with the dean's consent. There'll be no tolerance or what's he called "zero tolerance policy",,, no tolerance for neglection, no tolerance to what so ever but the only tolerance is for the hard-working students.

-Each surgery session is a little exam, 60% of the mark is for these little exams while the remaining 40% is for the final exam that's most probably would be as an OSCE exam.

- In the surgery clinic we are assessed according to the following points: problem assessment, examination skills, professional behavior, how you treat your patient, colleagues & the supervisors, how you give local anesthesia, how you perform the surgical procedures, the cross infection control & the resource use (ex. Using 4 carpules). Also there're drop-quizzes in sessions.

- Never ever forget to take a thorough medical history to your patient; and you have to update the medical history each time you meet the patient.

- You have to be able to take the vital signs for patients.

-You have to read the head & neck anatomy that you've taken in the 2^nd year (muscles, lymphatic drainage…etc).

-You have to know everything about the lymph nodes of the neck.

-Read about the nerve supply of the orofacial region.

-You have to go back to the neuroanatomy you've taken in the second year and read about the 12 cranial nerves.

-One of the quizzes for the coming 2 months is going to be about history & examination.

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History & Examination

* We have already talked about the topic of our lecture in the introductory course so this lecture doesn't contain rocket science!

-1) Basic information: You have to know your patient; his name, date of birth, hospital number & home address.

-The medical history is very important; because you treat the patient, give him medications, local anesthesia, do a surgery for him so you've to be ready to face anything would happen but the most important thing is not to be part of the carelessness that might happen and not to put the patient in a risk because many patients died on the dental chair.

-You have to know everything medically about the patient from the gynecology to kidney diseases, respiratory diseases not only the diabetes and hypertension.

-2) Chief Complaint: After taking the sociodemographic details, you have to ask the patient about the chief compliant. Most of patients come complaining of pain, when a patient come complaining pain, you have to ask him what's the type of pain, how long it has been therefore, nature (throbbing or sharp), aggravating factors, relieving factors (ex.panadol), what are the things that make the patient complaining of pain at one side of his face that's accompanied by headache; because we aren't only dentists, we're oro & maxillofacial physicians. You might deal with patients complaining of tension headache, TMJ problems, cranial nerve problems or dental problem. >> So you need to know everything about pain and you have to record everything down & follow-up the patient to monitor how your treatment improved the condition.

- 3) Medical history: In " Medical problems in dentistry for Crispian Scully", there's a chapter talks about medical history and suggests to go from (A to L) in order not to forget any system down from the (L) likelihood of pregnancy even the women in child-bearing age, you need to ask if they are pregnant, if they are planning pregnancy, if they are on the pill.

A	B	C	D	E	F	G	H	I	J	K	L
Anemia	Bleeding	Cardiorespiratoy	Drug treatment & allergy	Endocrine diseases	Fits & faints	GIT	Hospitalization	Infections	Jaundice & liver disease	Kidney disease	Likelihood of pregnancy

- (K) Kidney diseases affect you; because you're prescribing medicines and you need to know whether some medicines you are prescribing are actually excreted by the kidney.

- (J) Jaundice and liver disease are very important because you might deal with a patient infected with hepatitis. The liver is very important because it's the site of drug metabolism, therefore there're certain drugs you aren't be able to give. Liver is important for another function which's bleeding and coagulation factors (ex. Patient suffers from advanced liver disease, if he bleeds then he'll die).

- (I) Infections: all sorts of infection from common flu to tuberculosis, mononucleosis, HIV…etc. So you have to know about these things because you may need to modify your treatment plan or you decide not to do an elective procedure; an elective procedure is done in acute phases of illness.

- (H) You have to know whether your patient has been hospitalized over the past several years; because some patients may be hospitalized due to asthma or fits. So when a patient comes to you and he had been hospitalized due to asthma; this means that he had an advanced asthma that's unlikely to be controlled and if a severe asthmatic attack occurred while he's sitting on the dental chair, he may die.

- (G) Gastro-intestinal disease: like the peptic or gastric ulcer, so you won't prescribe NSAIDS for him. The doctor said you have to know why and here's what wiki says:

"The main adverse drug reactions (ADRs) associated with use of NSAIDs relate to direct and indirect irritation of the gastrointestinal (GI) tract. NSAIDs cause a dual assault on the GI tract: the acidic molecules directly irritate the gastric mucosa, and inhibition of COX-1 and COX-2 reduces the levels of protective prostaglandins. Inhibition of prostaglandin synthesis in the GI tract causes increased gastric acid secretion, diminished bicarbonate secretion, diminished mucus secretion and diminished effects on epithelial mucosa"

http://en.wikipedia.org/wiki/Non-steroidal_anti-inflammatory_drug#Gastrointestinal

- (F) Fits and faints, if the patient has history of repeated fits; I don't treat this patient electively unless I get his condition on the control then collaboration with his treating physician.

- (E) Endocrine disease from pituitary disease to diabetes mellitus (you need to know everything about diabetes).

- (C) Cardiorespiratory.

- (B) Bleeding disorders & (A) anemia.

*You should ask your patient about all these things. You should know what medicines they take. For example, if a patient takes aspirin, you can't prescribe NSAIDS for him. If a patient takes warfarin, you have to be careful in prescribing medicines. If the patient is pregnant, you have to be careful to certain teratogenic drugs. Some antihypertensive drugs have oral manifestations.

-4) Dental history: You need to know the dental history of your patient but we concentrate on the medical history.

-5) Clinical examination: After taking history, you have to start examining the patient.

**In medicine there're basic techniques for examination in any area of the body:

a) Visual inspection: As a clinician, you have to look at the patient's leg, abdomen face, mouth...etc. you have to look & notice if there's any swelling, redness, deformity, carious cavity, or any detached fillings and then you have to palpate & touch by your hands (by gloved hands).

b) Palpation: For example, if there's a swelling in cheeks, look, notice the size (ex.3X3). But why do we need to feel it?? To know if it's tender or not, painful or not, attached & fixed to the underlying tissues like cancer or not, or it's a fluid moving some sort of structures in the cheek or not, if its texture is hard, you have to know if it's smooth hard or heavily hard, if it's hot or has normal temperature.

c) Percussion & auscultation: In many areas in the body we need to percuss; percuss means to knock. Percussion is important because it helps in knowing if there's fluid inside or not. Percussion in dentistry is done by the dental mirror on teeth, when you percuss on teeth, you'll know if there's pus underneath it or not. When you percuss, it'll cause pain and gives a sound; normal sound bone or there's fluid underneath if it's a cyst. Auscultation, you hear by stethoscope the sound of the joint. Mass in the neck>>maybe it's hemangioma if there's bruit or not.

d) Periodontal probing: is essential in dentistry; it shows pocketing.

e) Aspiration: aspiration means to stick a needle inside a swelling and aspirate to see whether there's nothing, there's air, blood or fluid. We use this aspiration if there's a cavity or a cyst in the joint, jaw, in the neck, or in the parotid.

**Extraoral examination:

-In dentistry, the examination starts when the patient enters your clinic. You need to notice whether your patient is walking appropriately or using a walking stick, his appearance is healthy or not, his face is yellowish or normal, his hands & feet are moving appropriately. So from the patient's appearance you can predict whether he's normal or not, whether he has any sort of a disease that affects his general health or not.

-The vital signs are: temperature, pulse, blood pressure & respiratory rate. You need to know them, their definitions, the normal figures & you need to know how to measure them. Not every patient you meet you measure the vital signs but the vital signs should be a normal thing you perform in patients who have infections, any sort of infection that the patient is complaining of. For example, if a patient comes to your clinic and he has cheek swelling, can't sleep, can't swallow, he's skinny, exhausted (malaise), then you measure his temperature>> 39.4 C, measure his blood pressure>>low, measure the pulse rate from the radial artery>>high, measure the respiratory rate>> 25 while the normal is between 14-16. So there's toxicity and septicemia, now the infection spread not only localized to his tooth & cheek, the bacteria in his blood & in his systems>> this patient is not treated as we treat the dental abscess and if we didn't treat him properly, he'll die because of septic shock & multi-organ failure. This patient must be hospitalized immediately, start giving him IV antibiotics & fluids and start draining the collection of pus.

-You are dealing with an oro-facial region; you are part of health care team that could save the patient's life.

-After finishing all things we mentioned above, you go to the head & neck region. For example if a patient comes to your clinic wearing a cap, you should see his hair, he might be infected with lice then lice will become attached to your clinic, you may get the infection and the lice may cause typhus to the patient himself. So you need to make sure that you can see the patient's hair because he also may have fungal infection. Look at the face whether it's symmetrical or asymmetrical; because the patient may have one of the branchial arches disorders (syndromes)>> ex. If the patient has severe asymmetry; one side of his face is poorly developed, and other indications with growth & development of teeth, also he may have associated cardiac problems.

-You have to look at the eyes; we care whether the patient can see by his eyes, open & close, drooping of eyelids, ptosis or change in eye position.

-look at the ears; if there's malformation of one ear this could be a sign of hemifacial microsomia.

-TMJ: it's very important joint for our practice because a lot of patients come complaining of joint problems. When we talk about TMJ we don't mean only the joint itself but also the associated muscles & cranial nerves in that area. 1) The first test to examine the TMJ is whether the patient could open his mouth or not, the normal mouth opening is between 40-50mm>> so if a patient couldn't open his mouth to that extent, there'll be a problem in the joint. 2) Then does the patient opens his mouth in a straight line or deviate. If there's deviation during opening or closing then there's a problem in the joint or in the muscles. 3) Palpate the joint during opening; if there's pain upon palpation, this means there's a problem in the joint or muscles. 4) Auscultation during opening; if there're sounds. Does it click during opening? Does it click during closing? Or does it click during opening & closing? Is there any crepitation?

-You need to examine the parotid gland, nose & paranasal sinuses>> the doctor said go and read how to examine them from your book.

-Neck examination is part of your final exam. You need to know how to examine the neck. Ex. If there's lymphoma, lymph node metastasis due to oral squamous cell carcinoma. In the neck there're: trachea, carotid vessels, cranial nerves, lymph nodes & muscles. You need to examine them all starting from sternocleidomastoid muscle; because sternocleidomastoid & trapezius muscles are part of the faciocervical muscloskeletal system and may manifested as TMJ disorder.

-Lymph nodes: you need to test the lymph nodes and the neck is full of lymph nodes>> also the doctor said that you have to read about lymph nodes from the anatomy book and you'll be asked about it in the exam. You have to know their distribution, type of cervical chains of lymph nodes; submandibular, submental, jugulodigastric…etc. you'll be asked in the mid-term exam about the lymphatic drainage. When you examine the lymph nodes; their size is very important. It maybe soft &tender (infection) or hard fixed (cancer). If a patient comes complaining of a mass in the neck that's soft & tender, you have to know that this lymph node is draining certain part of mouth & face and there's infection in part of the mouth & face. Most of the oral region eventually drains in the submandibular lymph nodes. If a patient comes complaining pain in the lower 6, and it's tender to percussion>>then test the submandibular lymph nodes and it's likely to find tenderness then prescribe oral antibiotics but you need to treat the cause (tooth) because whenever there's spread of infection to lymph nodes, you need to treat the patient.

-The dr. showed us pictures for examining the submental lymph nodes and the cervical chain lymph nodes….examining the lymph nodes is done by levels 1,2,3,4,5 we'll learn in the clinic how to examine them. If we discovered an abnormality in the lymph node, we'll save the patient's life.

-You have to read about the 12 cranial nerves; you need to know their names & their functions. Especially, two nerves you need to know everything about them 5^th (trigeminal) & 7^th (facial). The facial nerve innervates muscles of facial expression while the trigeminal nerve gives sensation to the mouth & face and an extramuscular nerve to muscles of mastication. The rest of the cranial nerves, you need to know some points about them. Ex. The olfactory nerve is affected by trauma (smelling), the optic nerve is also affected by trauma & some diseases such as multiple sclerosis. The occulomotor, trochlear & abducent move the eye, ex. a patient may come complaining diplopia because one of these nerves is affected. You need to know how to test the trigeminal nerve; because a patient may come and he lost sensation in some parts of his face; you need to examine that patient thoroughly; because there maybe extracranial or intracranial causes for this numb sensation or disturbance in the sensitive function. The facial nerve is very important; because we'll deal with patients who have facial palsy; one side of the face isn't working properly. You need to know the causes; whether extracranial or intracranial causes in order to diagnose the patient and transform him to the concerned authorities. In oral medicine you'll learn what facial palsy is and how we treat it. The auditory, glossopharyngeal, vagus, accessory (for trapezius), hypoglossal (for the tongue).

-Intraoral examination without extraoral examination is rubbish. When we move to the oral cavity the worst thing you do is to start examining teeth! You must start examining all the soft tissues then you move to the teeth. (Buccal mucosa, tongue (the 2 surfaces), floor of the mouth, palate, oropharynx & gingiva then you move to teeth). We discover many cases with malignant or premalignant lesions for patients come for general check, or for patients come for TMJ, or come for wisdoms.

-After you finish examination, write a problem list and start with the most significant or the problem that a patient is complaining of. Ex. a patient has pain from dentoalveolar abscess of lower 6, the patient has multiple caries, white lesion…etc and according to the problem list start making a treatment plan (ex. give the patient antibiotics, extract the lower 6 if non-restorable, take a biopsy for the white lesion, refer to a periodontist to do a perio treatment).

*Oral Surgery lec.# 1 *Date of the lec.: 20.9.2011

*Dr.Zaid Bqaeen *Written by: Wafa'a Iseid