Lecture Notes on the Basic Principles of Surgery

2.
The Basic Principles of Surgery
• Making a positive final diagnosis
• Preoperative Assessment and Prevention of Emergencies
• Principles of painless surgery
• Principles of surgery
• Wound repair
• Infection control
• Postoperative patient management

3.
Making a positive final diagnosis
Diagnosis sequence
• Patients chief complaint
• Initial examination of the mouth
• History of the present illness
• Medical and dental history
• Physical examination
• Formulating a Differential Diagnosis
• Radiographic examination and laboratory tests
• Biopsy when indicated
• Securing a Definitive Diagnosis

4.
Common Chief Complaints of Dental Patients
• Oral pain
• Mucosal lesion: swelling, ulcer, and white lesion
• Mobile teeth
• Bleeding from around the teeth
• TMJ click
• Bad smell
• Limited jaw opening
• Altered sensation: bad taste, burning sensation in the mouth

1
5-8
Oral pain is one kind of sensations in the body
• Special sensation: Vision, olfaction, hearing, and taste
• Ordinary sensation: nociception (pain), thermoception (heat and cold),
mechnoception (touch and pressure, vibration, and texture),
proprioception (sense of position)

Note 1: The principle sensory supply to the mouth and teeth is the trigeminal
nerve. The periodontium is supplied by all forms of ordinary sensation.

Note 2: The pulps of the teeth are supplied only by nociception through the A-
fibers and C-fibers. The A-fiber endings are located in the peripheral pulp and
inner dentin. They are responsible for dentin sensitivity, and their activation in
healthy teeth results in sharp and usually short-lasting pain, not outlasting the
stimulus. The C-fibers are polymodal and respond to several different noxious
stimuli. In the pulp they are activated during inflammation. It seems that they
may conduct the dull pain or ache in pulpal inflammation

9
Causes of Oral Pain
• Dental pain (75% of oral pain)
• Gingival pain: pericoronitis
• Periodontal pain
• Bone pain: periapical periodontitis, dry socket, pain associated with
denture base
• Neurogenic pain: Trigeminal neuralgia
• Myogenic pain: TMJ pain, masticatory muscle pain
• Psychogenic pain: Atypical odontalgia, burning mouth syndrome

11.
Dental pain
• Dentinal pain - Pulp is healthy, but dentinal tubules are exposed to the
environment, which can cause pain.
• Pulpal pain - The status of the pulp can range from normal to necrotic
(dead).

2
 • Periapical pain - As the necrotic products work out from the apex, there is
inflammation and pain in the periapical area.

12-20
Dentinal pain
Note 1: Evidences support the theory that the dentinal tubules allow for a
continuous outflow of extracellular fluid from the pulp toward outside. This
extracellular fluid would imbibe through the enamel and cementum to reach the
external surfaces of the teeth. It is claimed that sudden acceleration or
deceleration in the flow of this fluid would trigger action potentials in the A-
fibers. These action potentials could pass to the brain causing pain.

Note 2: Main causes of dentinal tubes exposure to outside include the dental
caries, broken and cracked teeth, gum recession and periodontal pockets

Note 3: Clinical presentation of dentinal pain:

Sharp stabbing 'nerve' type pain, always related to a hot, cold or sweet stimulus;
the pain is never spontaneous (i.e. a stimulus is always needed).
Pain occurs immediately following application of the stimulus and is reasonably
well localized (the patient can point to the area and often the tooth involved).
Immediate relief follows removal of the stimulus.

22-29
Causes of pulpal pain
• Dental caries
• Traumatic exposure of the pulp
• Fracture of a crown or cusp
• Cracked tooth syndrome
• Thermal or chemical irritation

Note 1: Reversible (or transitory) pulpitis is the condition where the pulp is only
inflamed because it is actively responding to an irritant.

3
Most often, the irritants are bacteria from a carious lesion that has not reached
the pulp. Other types of irritants can be very hot agents (for example from
repeated dental procedures), harmful chemical agents etc.

Note 2: Clinical presentation of reversible pulpitis:

• Pain does not occur without stimulation: Although heat may initiate pain,
the affected tooth responds most to cold stimuli. Contact with sweet or
sour foods and beverages also may cause pain.
• Pain disappear on removal of stimulus
• Very short duration (< 30 seconds)
• No spontaneous pain
• Mobility and sensitivity to percussion are absent.
• Poorly localized

Note 3: Irreversible pulpitis is a condition where the pulp is irreversibly damaged.

Most often, the decay that has reached the pulp of the tooth introduces
bacteria into the pulp. The pulp tissue is still alive, but the presence of bacteria
in the pulp do not allow the pulp to heal up and this ultimately result
in necrosis, or death, of the pulp tissue.

Note 4: Clinical presentation of acute irreversible pulpitis:

• The pain is generally severe on thermal stimulation, and continues after the
stimulus is removed. In the later stages, however, heat increases the pain
but cold may produce relief.
• Sweet and acidic foods also can elicit pain.
• The pain may be spontaneous or continuous and may be exacerbated when
the patient lies down.
• Poorly localized
• Mobility and sensitivity to percussion are usually absent because
significant inflammation has not spread yet to the apical area.

31-38
Gingival and other periodontal pain
Note 1: Pericoronitis: Painful erythematous enlargement of the soft tissues
overlying the crown of the partially tooth.

4
Note 2: Clinical presentation of pericoronitis:
• Pain and tenderness around the partially erupted tooth
• The pain may radiate to the throat, ear, or floor of the mouth.
• The affected area is erythematous and edematous
• There is difficulty in opening the mouth. This difficulty may be severe
enough to prevent examination of the area.
• The patient often has lymphadenopathy, fever, leukocytosis, and malaise

Note 3: A periodontal abscess often arises in a preexisting periodontal pocket

and usually is precipitated by alterations in the subgingival flora, host resistance,
or both. Factor frequently associated with abscess formation is closure of the
entrance into a periodontal pocket.

Note 4: On occasion, an abscess may be localized to the marginal or interdental

gingiva without involvement of the adjacent periodontal ligament or alveolar
bone. This lesion is termed a gingival abscess and often is secondary to plaque or
foreign material that has become entrapped in the gingival sulcus.

Note 5: Clinical presentation of gingival abscess

• Throbbing pain
• Extreme sensitivity to palpation of the affected gingiva
• Sensitivity, mobility, or extrusion of the adjacent tooth
• Foul taste
• Lymphadenopathy

40-51
Bone Pain
Note 1: In acute apical periodontitis, the inflammation is sandwiched between the
tooth and the bundle bone lining the socket in the apical region. This would push
the tooth up rendering it tender to percussion and bite.

Note 2: clinical presentation of acute apical periodontitis:

• The tooth is at first uncomfortable, then increasingly tender, even to mere
touch.
• Hot or cold substances do not cause pain in the tooth.

5
 • As inflammation becomes more severe and pus starts to form, pain
becomes intense and throbbing in character.
• Exudate may penetrate overlying bone and periosteum a day or so after the
onset of pain, allowing relief of the pressure. Pain quickly abates but
exudate distends the soft tissues to form a swelling.

Note 3: In dry socket the affected extraction site is filled initially with a dirty gray
clot that is lost and leaves a bare bony socket

Note 4: Clinical presentation of dry socket:

• Typically, severe pain, foul odor, and (less frequently) swelling and
lymphadenopathy develop 3 to 4 days after extraction of the tooth.
• On occasion, the pain radiates from the socket to the ipsilateral ear,
temporal region, or eye.

Note 5: Bone exostosis and tori in edentulous areas can cause pain if the
prosthesis is not relieved properly.

53-57
Neurogenic Pain
Trigeminal Neuralgia

Note 1: Stimuli to an area (trigger zone) within the distribution of the trigeminal
nerve can provoke an attack. Common stimuli are touching, draughts of cold air,
or tooth brushing. Occasionally, masticatory effort induces the pain.

Not 2: Diagnosis of trigeminal neuralgia:

A. The onset of a pain “attack” is abrupt, often initiated by a light touch to a
specific and constant trigger point.
B. Occurring in one or more divisions of the trigeminal nerve, with no radiation
beyond the trigeminal distribution
C. Pain has at least three of the following four characteristics:
1. Recurring in paroxysmal attacks lasting from a fraction of a second to 2 minutes
2. Severe intensity
3. Electric shock–like, shooting, stabbing, or sharp in quality

6
D. No clinically evident neurological deficit

59-62
Myogenic Pain
The pain is due to myospasm.

Note 1: Clinical presentation of TMJ pain and dysfunction syndrome

• Pain usually one-sided, rarely severe
• Typically, a dull ache is made worse by mastication
• Pain typically felt in front of the ear. Sometimes pain is felt lower down
over the ramus, occasionally at the angle of the jaw and more rarely still,
other sites nearby.
• The TMJ area may be tender to pressure and a clicking sound, when the
mouth is opened or closed, is common.
• Frequently also limitation of opening, or 'locking' of the jaw

Note 2: In the internal derangement of the TMJ, the lateral pterygoid muscle
undergoes chronic spasm causing anterior dislocation of the disc associated with
chronic pain.

64
Psychogenic Pain
Note: Diagnosis of atypical odontalgia and burning mouth syndrome
can only be achieved after exclusion of other organic causes for the pain.

75
Causes of swellings in mouth
Note: Peripheral swelling = swelling originate in soft tissues
Central swelling = swelling originate and grow in bone

7
76
Causes of peripheral swellings in mouth
• Developmental: Haemangioma, lymphangioma.
• Trauma: Fibrous epulis, fibroepithelial polyp, denture granulomas
• Infection and inflammation: Pyogenic granuloma
• Cystic and cyst-like lesions: Eruption cysts, mucocele
• Tumors: Benign and malignant

77-82
Developmental swellings
Note 1: Submucosal (superficial) hemangioma appears as bluish swelling that may
blanch when pressed down by the palpating finger to reappear after release of
the pressure

Note 2: Intramuscular hemangioma, on the other hand, is not discolored.

Note 3: Lymphangioma is one of the most common cause of macroglossia

83-96
Traumatic swellings
Note 1: Loss in continuity of the epithelium is an ulcer. The bed of the ulcer soon
become inflamed, and if the cause of the ulcer no more present or removed,
healing by epithelial growth from both sides of the ulcer shall take place.
Persistence of the cause of the ulcer can interfere with healing and may be
complicated by an outward inflammatory growth from the connective tissue
through the overlying ulcerated epithelium. The inflammatory growth soon
epithelized and a fibro-epithelial polyp forms.

Note 2: Fibro-epithelial polyp can occur on the gingiva where it is called epulis as
any localized swelling in the gingiva is called epulis regardless of its cause.

Note 3: The denture granuloma is another form of traumatic swelling that is

caused by an ill-fitted denture with long flange.

8
97-99
Inflammatory swellings
Note: The pyogenic granuloma is a smooth or lobulated mass that is usually
pedunculated. Typically, the mass is painless, and it often bleeds easily because of
its extreme vascularity.

100-102
Cysts and cyst-like swellings
Note 1: Eruption cyst is a soft tissue odontogenic cyst arising from the follicle of
an erupting deciduous or permanent tooth. It may be dark red when it is blood
filled.

Note 2: the mucocele is a blue-pigmented nodule on the oral mucosa, particularly

of the lower lip, and caused by extravasation of saliva underneath the oral
mucosa. Although, it clinically looks like a cyst, but it is not a true cyst as it
contains no lining.

103-105
Soft tissue tumors can be benign or malignant:
Note: Benign tumors in the mouth are usually covered by healthy looking mucosa.
The mucosa itself is not tethered to the tumor
Malignant tumors of the oral mucosa are mainly squamous cell carcinoma. The
mucosa is ulcerated and tethered to the tumor

106
Causes of central swellings in mouth
• Developmental: Central haemangioma, maxillary and mandibular tori and
exostosis
• Infection: Odontogenic infection, osteomylitis
• Cystic: Odontogenic cyst
• Tumors: Benign and malignant

9
107-110
Developmental swellings
Note: The torus palatinus is a common exostosis that occurs in the midline of the
vault of the hard palate. Torus mandibularis is usually a bilateral lobulated bony
protuberances of the mandibular lingual alveolar ridge. Buccal exostoses occur as
bony hard nodules along the facial aspect of the maxillary and/or mandibular
alveolar ridge

111-115
Infection
Note 1: Odontogenic infection may point out and discharge to the vestibule. The
discharging point is called parulis and appear as a nodule in the vestibule

Note 2: jaw osteomyelitis is mainly occurs in the mandible and can cause both
extra and intraoral swelling. In its acute stage, mandibular osteomyelitis can be
associated with paresthesia or numbness along the territory of mental nerve
innervation

Note 3: The plain jaw X-ray film in acute osteomyelitis can show radiolucency with
ill-defined borders

116-118
Odontogenic cysts
Note 1: Odontogenic cyst can cause swelling when expands the buccal cortex of
the jaw bone. The overlying mucosa looks normal and mobile

Note 2: The plain jaw X-ray film of an odontogenic cyst can show radiolucency
with well-defined borders associated with the crown of an impacted tooth or the
root of an erupted one.

10
119-124
Tumors
Note 1: Benign tumors of jaw bone usually show themselves as slowly growing
swelling that is covered by healthy looking mucosa with the plain X-ray film shows
a well-defined radiolucency.

Note 2: Malignancies in jaw bone are usually destructive and of shorter history.
They are usually covered by an ulcerated mucosa and their plain X-ray film
demonstrate a radiolucency with ill-defined borders.

Note 3: Malignancies in jaw bone are usually destructive and when involve the ID
canal in the mandible or the inferior orbital nerve in the maxilla can cause
numbness in the lower lip or infraorbital tissue and the upper lip respectively.

125
Diagnosis of swelling
• History
• Clinical examination
• Special investigations

126
History
• How long have you had the swelling? (Present at birth or early in life, likely
to be developmental. Recent onset suggests an acquired lesion).
• Is it painful? (Pain indicates infection (e.g. abscess/cellulitis). trauma or
secondary infection (of malignant tumors and cysts). Others are usually
painless).
• Has there been any discharge? (Infections may discharge spontaneously,
intra-orally or onto the face).
• Do you have any numbness of your lower lip or face? (Indicates a fast-
growing lesion or direct nerve involvement).

11
127
Examination
• Palpate the swelling to ascertain its tissue of origin, e.g. bone, or soft
tissue.
• Look at the patient's general condition. Swellings associated with recent
weight loss and cachexia suggest malignancy.
• Note any tenderness. redness or warmth (indicates inflammation or
infection).
• Assess the consistency:
Soft: e.g. lipoma, oedema.
Firm: e.g. fibrous epulis. fibro-epthelial polyp, cellulitis.
Hard: e.g. osteoma. odontogenic tumors.
• Check for fluctuance: Indicates there is fluid present, e.g. abscesses and
cysts in the soft tissues.
• Determine whether the swelling is fixed to the overlying mucosa by trying
to move the mucosa over it. Fixation is seen in both abscess and
malignancies.
• N.B. It. is essential to examine relevant lymph nodes and if palpable. record
details of the site, size and consistency

128-129
Manual examination of a swelling
Note: Diagnosis of fluctuance. Two tests must be carried out at right angles to
each other to confirm fluctuance. The index finger which depresses the swelling
causes fluid to be displaced and this is detected by the two 'watching' fingers at
the periphery of the swelling.

130
Special investigations
Note 1: All medical imaging including X ray film, CT scan, MRI, and ultrasound
views do not tell the final diagnosis. They can only help with formulating the
differential diagnosis and in identifying the extensions and size of the lesion.

12
Note 2: The biopsy is the only investigation that tells the final diagnosis

131- 147
Biopsy procedure
Note 1: Administer local anesthetic, by regional block where possible.
In any event, local anesthetic should not be closer than 2 cm from the site, to
avoid 'waterlogging' of the specimen with anesthetic solution, and spreading of
malignant cells should the lesion is malignant

Note 2: Incisional biopsy is may risk shedding malignant cells. Therefore, it is

applicable if the lesion is large or there is a suspicion of malignancy.

Note 3: Incisional biopsy should not be performed on pigmented or vascular

lesions. (Melanoma is highly metastatic and a vascular lesion may bleed
excessively.)

Note 4: The excisional biopsy may also risk shedding malignant cells if the
provisional diagnosis of benign lesion is incorrect. Therefore, it is used only when
the clinician is fairly certain that the lesion is benign.

Note 5: The excisional biopsy is applicable to lesions, smaller than 1 cm diameter

and it constitutes the definitive treatment if the diagnosis of benign lesion proves
correct.

Note 6: The aspiration biopsy:

• ls applicable to many cystic and fluctuant (i.e. fluid-containing) lesions.
• Failure to aspirate from a lesion suggests that it is solid.
• Aspiration of air from the molar region of the maxilla suggests that the
needle is in the maxillary sinus. This may help to differentiate the sinus
from a possible cyst.
• Aspiration of blood suggests a haematoma. haemangioma or blood vessel.
• Aspiration of pus indicates an abscess or infected cyst.
• Aspiration of keratin, a straw-colored fluid, or cholesterol crystals indicates
an odontogenic cyst.

13
149
Oral ulceration
Note: Causes of oral ulceration are many and may broadly classified into:
1. Those acting on the epithelium from above, e.g., physical, chemical and
thermal injury.
2. Those acting from within the epithelium, e.g., viral infection like the herpes
infection and the immunologically mediated diseases that target the desmosomes
and hemi desmosomes (vesiclobullous disease). Squamous cell carcinoma is also a
common cause of oral ulceration that originate from within the epithelium
3. Those acting from underneath the epithelium, e.g., an extending malignancy
from underneath

153-162
Oral ulcer
1. Acute Ulcer:
• Acute solitary ulcer: Traumatic ulcer, aphthus ulcer
• Acute multiple ulcers: Viral infection
2. Chronic Ulcers:
• Chronic solitary ulcer: Traumatic ulcer, infective ulcer, squamous cell
carcinoma
• Chronic multiple ulcers: Vesiculobullous disease
3. Recurrent Ulcers:
• Recurrent solitary/multiple ulcers: Recurrent aphthus ulcerations, recurrent
herpes infection

Note 1: The aphthus ulcer usually a yellowish ulcer with an erythematous halo
encircling it. It occurs anywhere in the mouth but mainly on non-keratinized
mucosa

Note 2: The traumatic ulcers usually appear as a single, painful ulcer with a
smooth red or whitish-yellow surface nearby a sharp edge of a tooth or
prosthesis. They heal without scarring within 6–10 days after removal of the
cause. However, if an ulcer persists over 10–12 days a biopsy must be taken to
rule out cancer.

14
Note 3: The TB ulcer is with usually painful and with undermined edges.
Histopathology of the ulcers showed caseation necrosis. Sputum microscopy
demonstrate the tuberculous bacilli. Chest radiography may reveal pulmonary
tuberculosis.

Note 4: Squamous cell carcinoma ulcer is usually painless unless secondarily

infected. It appears as a depressed, irregularly shaped ulcer with a necrotic bed
and a surrounding “rolled” border. It appears indurate (thick) and tethered (fixed
to underlying structures) when palpated.

163
Examination of ulcer
• Number of ulcers: multiple ulcers suggests viral infection. e.g. oral herpes ;
or recurrent aphthi
• Floor: sloughy (trauma), fungating, granulation or bleeding (malignancy).
• Base: indurated, fixed to deeper structures. Induration and fixation suggest
malignancy.
• Edge: flat with halo (aphthus ulcer), raised, rolled and everted (malignant
ulcers). Undermined (tuberculous ulcers).
• Associated problems: fever (viral infections are typically associated with
fever), pain (inflammatory and infective ulcers are painful),
lymphadenopathy.

166-167
Causes of limited mandibular opening
• Trauma, e.g. third molar surgery and local anaesthetic injection.
• Infection. e.g. pericoronitis, submasseteric, pterygomandibular space
infection.
• Tumors
• Scar tissue formation, e.g. post-irradiation, and burns.
• Central nervous system disorders, e.g. tetanus.
• Psychological, e.g. hysteria.

15
Note 1: Spasm of the muscles that closes the jaw (temporal, masseter, and medial
pterygoid) causes trismus. These muscles can be irritated by: (1) trauma from
surgery or needle injection, (2) dental infection that is spreading backward,
particularly from pericoronitis associated with a partially erupted third molar.

Note 2: Malignant tumors medial to mandibular ramus can irritate the medial
pterygoid and temporalis muscles causing trismus

Note 3: Tetanus is a serious systemic clostridial infection. It follows inoculation of

the clostridia tetani that liberate the tetanus neurotoxin. These causes neuronal
stimulation and spasm of the skeletal muscles. The earliest manifestation is lock-
jaw or trismus. Death occurs due to spasm of respiratory and laryngeal muscles.

169
Preoperative Assessment and Prevention of Medical Emergencies
Most common medical emergencies that can develop during dental treatment
include:
• Chest pain: Anxiety, myocardial infarction (MI), angina pectoris
• Difficulty in breathing : Anxiety, MI, angina, anemia
• Altered consciousness: Simple faint, hypoglycemia, epileptic seizure,
cardiac arrest, stroke, adrenal crisis

170
Preoperative Assessment and Prevention of Medical Emergencies
1. Inquiring about health conditions
2. Review of systems:
Cardiovascular system
Respiratory system
3. Examination of vital signs

16
171
Inquiring About Health Conditions
• Have you had any serious illness or operation?
• Do you have or have you had any of the following diseases or problems?:
(1) Cardiovascular disease (heart trouble, angina, high blood pressure, stroke)
(2) Asthma
(3) Diabetes
(4) Kidney trouble
• Are you taking any of the following drugs: Medicine for high blood
pressure, nitroglycerin, aspirin, steroids, tranquilizers, insulin or similar
drug for diabetes.

172
Reviewing the Cardiovascular System
• Chest pain
• Dyspnea – difficult breathing
• Paroxysmal nocturnal dyspnea
• Orthopnea (breathlessness on lying flat)
• Ankle edema
• Palpitations (an awareness of the beating of the heart)
Notes: Dyspnea is caused by cardiac, respiratory disorders or anemia
Paroxysmal nocturnal dyspnea is sudden respiratory distress related to reclining
at night. Most commonly seen with congestive heart failure and pulmonary
edema.
Ankle edema may occur when venous pressure rises in cardiac failure.
Palpitations are most commonly caused by arrhythmias, anemia, and
thyrotoxicosis. When associated with chest pain, the palpitations may indicate
cardiac ischemia.

173
Reviewing the Respiratory System
• The presence of cough
• Whether the cough is productive of sputum or not

17
 • Hemoptysis (coughing up blood)
• Wheeze (a continuous whistling noise)
Notes: Hemoptysis may result from bleeding within the respiratory tract. It is
most commonly seen in diseases such as tuberculosis, bronchitis, lung abscess,
tumors and congestive heart failure.
Wheezing may result from constriction of the throat, trachea, or bronchi. It is
common in asthma and congestive heart failure

174
Examination of vital signs
• Pulse rate
• Blood pressure
• Respiratory rate
• Body temperature

175-180
Examination of pulse rate

Pulse rate
• 60–80bpm (resting pulse)
• Bradycardia (< 60bpm ): old age, hypothyroidism, vasovagal attack
• Tachycardia (80–100bpm): thyrotoxicosis, infection, anxiety

Note 1: Sever tachycardia (flutter and fibrillation) reduces cardiac output because
of reduces stroke volume. This can lead to loss of consciousness.

Note 2: Bradycardia, especially when associated with heart disease, can cause
sudden loss of consciousness (syncope).

18
182
Blood Pressure (BP)
• BP is normal within the range 120-140 mmHg (systolic), 60-90 mmHg
(diastolic)
• Routine dental treatment is deferred if the patient has severe hypertension
(Systolic pressure is equal or more than 180 mmHg, Diastolic pressure is
110 mmHg)
Note 1: Sever hypertension may lead to stroke (cerebrovascular accident) with
subsequent loss of consciousness. It can also predispose to angina or acute
myocardial infarction with chest pain as a first manifestation.

Note 2: Hypotension can cause loss of consciousness secondary to reduced

cardiac output

183
Respiratory rate
• The normal respiratory rate in a resting adult who is fit and well is 12–18
breaths/min.
• It is increased by: thyrotoxicosis, chest infection, exercise, and anxiety
• May decrease by narcotics

Note 1: Tachypnea or hyperventilation is excessive, rapid and deep breathing,

resulting in a fall in the carbon dioxide level in the blood. This would lead to
reduced cerebral circulation with subsequent loss of consciousness.

Note 2: Hypopnea can be a cause of reduced oxygen saturation with subsequent

reduction of oxygen splay to the brain. This would, in turn, leads to loss of
consciousness.

19
184
Body temperature
• The normal body temperature, measured orally, should be within the
range 36.2-37.8°C.
• Body temperature may be raised due to:
Infection
Surgery
• Body temperature may be lowered due to:
Hypothermia
Severe shock

Note: Hyperthermia can cause peripheral vasodilation with secondary drop in

blood pressure. It may also leads to loss of enzymatic control of the body. This
would, in turn, affects the functioning of major organs with high energy demands
such as the heart and brain.

186
Principles of Painless Surgery
• Prevention of intraoperative pain
• Control of postoperative pain

187
Prevention of Intraoperative Pain
• Local anesthesia (LA)
• LA + Sedation

20
188
Local anesthetics
• Xylocaine 2% plain
2% + 1:100,000 adrenaline
2% + 1:200,000 adrenaline
• Articaine 4% + 1:100,000 adrenaline
4% + 1:200,000 adrenaline
• Prilocaine 4% plain
4% + 1:200,000 adrenaline
• Marcaine 0.5% + 1:200,000 adrenaline

Note 1: Short duration: pulpal anesthesia about 30 min.

Intermediate duration: pulpal anesthesia about 60 min.
Long duration: pulpal anesthesia 90 min. and more

Note 2: Local anesthetics with 4% concentrated can be neurotoxic. Therefore,

they are better be avoided during a regional block anesthesia giving.

190
Principles of local anesthesia
• Knowledge is required about:
1. Choice of the local anesthetic
2. Number of LA cartridges that can be administered safely
3. Safety of LA in pregnancy
4. Proper administration of the injection

191-194
Choice of the local anesthesia
• Duration
• Need for hemostasis
• Anticipated degree of pain
• Medical history

21
Note 1: Most of oral surgery procedures can be carried out with the use of one of
the 2% xylocaine+ 1:200,000 adrenaline.

Note 2: 2% xylocaine+ 1:100,000 adrenaline will be needed for surgeries with

more bleeding than usual, e.g., reflection of supraperiostal flap

Note 2: Plain local anesthetics can be used when short anesthesia is required,
e.g., incising a vestibular abscess and extraction of an excessively mobile tooth

Note 3: The use of an adrenaline-containing local anaesthetics should be avoided

for patients with:
Systolic blood pressure > 200mmHg
Diastolic blood pressure > 115mmHg
Unstable angina
Untreated hyperthyroidism.
For these patients, a plain 4% prilocaine is a useful alternative to 2% xylocaine
with adrenaline.

Note 4:
(1) The maximum safe dose of 2% xylocaine+ 1:200,000 for an otherwise healthy
adult is 13 two ml carpules.
(2) The maximum safe dose of 4% prilocaine+ 1:200,000 for an otherwise healthy
adult is 8 two ml carpules.
(3) The maximum safe dose of 4% articaine+ 1:100,000 for an otherwise healthy
adult is 5 two ml carpules.
(4) The mnaximum safe dose of 2% xylocaine+ 1:200,000 for an adult with cardiac
problem is 2 two ml carpules.

Note 5: Xylocaine and prilocaine are belong to the category B local anaesthetics
and are safe during pregnancy and lactation unless excessive amounts are
administered.
All other local anaesthetics are belong to category C and are generally harmful to
the mother and the lactating child

22
195
Proper administration of the injection
• Slow injection
• Always supraperiosteal
• Not in inflamed or infected area
• Aspirate before injection
• Observe the patient after completion of the injection
• Self-protection from a needle stick injury

197
Principles of sedation
• Sedation is a state of depression of the central nervous system enabling
treatment to be carried out, but during which verbal contact with the
patient is maintained throughout the treatment

198
Principles of sedation
• The patient should be generally fit and well.
• Consent the patient before administration of sedation
• Patient with sedation should not be allowed to drive or operate machinery
for the remainder of the day of administration

199
Oral sedation
• It is used principally to alleviate fear and anxiety
• Oral sedation is unpredictable in its effects
• Temazepam 10–30 mg taken 1h pre-operatively
• Diazepam 5–15 mg. a suitable adult regime may be 5 mg the night before
the treatment, 5 mg on waking and 5 mg 1 h before the procedure.

23
201
Inhalational sedation
• Simple anxiolysis it is also useful in patients who have a hyperactive gagging
reflex
• The relative contraindications to the use of inhalational sedation include
upper respiratory tract infections that make nasal breathing difficult.

202
Intravenous sedation
• Intravenous sedation is indicated for:
1. A group of patients with anxieties and phobias related to dentistry.
2. A group of patients who have considerable difficulty with vasovagal attacks
prior to and during dentistry.

Note 1: Valium: give slowly intravenouslly in 2.5-mg increments until ptosis begins
(i.e. eyelids begin to droop; Verrill’s sign). Rapid injection may cause respiratory
depression.

Note 2: Medazolam: Inject 2–3 mg of midazolam over 30 s and assess the

patient’s response over the next 2–3 min. Administer further 0.5–1 mg
increments of midazolam at 2-min intervals until adequate sedation is achieved,
as indicated by a relaxed but cooperative patient with slight speech slurring.

Note 3: Medazolam is always preferable to valium. This is the midazolam is water

soluble and less irritant to the intima of the selected vein, i.e., the chance of
phlebitis development is less after midazolam than after the valium use.

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207
Principles of surgery

208
Basic Necessities for Surgery
(1) adequate access
(2) adequate light
(3) a surgical field free of excess blood and other fluids.

214
Incisions
• A sharp blade of the proper size should be used
• A firm, continuous stroke should be used when incising
• Avoid cutting vital structures when incising.
• The incisions should be made with the blade held perpendicular to the
epithelial surface.
• The incisions should be properly designed and placed.

217-228
Flap design
• Prevention of Flap Necrosis
• The flap must be of adequate size
• The flap should avoid injury to local vital structures in the area of the
surgery

230-235
Hemostasis
• Pressure
• Ligation
• Thermal coagulation
• Use of vasoconstrictors

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237-254
Principles of wound repair
• Control of bleeding
• Elimination of dead space
• Closure of the wound without tension
Note 1: failure to ensure complete hemostasis before wound closure could lead
to hematoma formation. Hematoma could can be a cause of postoperative
infection and may affect the airway when become an expanding one.

Note 2: Dead space = a space remaining in the tissues as a result of failure of

proper closure of the wound, permitting the accumulation of blood or serum.

Note 3: Dead space in bone after removal of large cyst or benign tumor can be
dealt with by: (1) filling the space by bone graft or any bone substitute material,
or (2) packing the space opened

Note 4: dead space in soft tissues can be dealt with by layer closure of the wound
and by the use of surgical drains. Surgical drains are of two types: (1) an open
drain that allows for external drainage of the accumulated fluids only, and (2) a
closed vacuum drainage which, in addition to drainage of the accumulated fluids,
causes negative pressure inside the wound. This would cause the skin to collapse
over the wound bed eliminating the dead space.

256
Principles of Asepsis and Prevention of Wound Infection
• Sterilization of instruments and equipments
• The use of prophylactic antibiotics

257
Instruments and equipment
Note:
(1) Critical items: These include any item that is used to penetrate soft tissue
or bone. These items should be sterilized by heat sterilization (hot oven or an
autoclave)
(2) Semi-critical items: These include any item that enter the mouth but do
not penetrate the oral mucosa. These items can be sterilized by chemicals, but

26
 when become contaminated by blood they should either be disposed of or
sterilized by heat sterilization
(3) Noncritical items: These include any item that do not enter the mouth but
can touch the skin. They are either wrapped by disposable sheetings or wiped
by a suitable chemical.

258
Critical items
• These items are used to penetrate soft tissue or bone.
• Examples: surgical instruments, scalers, forceps, scalpels, bone chisels, burs
• Since the risk of transmission would be high, they must be heat sterilized
• Techniques of heat sterilization include the dry and moist heat use. Moist
heat sterilization is more efficient than dry heat for sterilization because it
is effective at much lower temperatures and requires less time.
259
Dry heat sterilization
• 160°C for 2 hours or 170°C for 1 hour.
• Times for dry-heat treatments do not begin until temperature of oven
reaches goal.
• Dry heat is most commonly used to sterilize glassware and bulky items that
can withstand heat but are susceptible to rust.

260
Moist heat sterilization
• 125 0C at 20 psi for 16 minutes or 132 0 C at 20 psi for 4 minutes

262
Semi-critical items
• Touch mucous membranes or intact skin
• Examples: mouth mirrors, amalgam condensers, impression trays, x-ray film
holders
• Have a lower risk of transmission. However, if an item can be heat
sterilized, it should be heat sterilized.

27
 • Semicritical instruments which cannot tolerate the high temperatures must
be processed by chemical disinfection

263
Chemical disinfection
• 2% Gluteraldehyde (Cidex), 10 hour contact time when high activity level of
disinfection required
• 2% Gluteraldehyde (Cidex), 10 minutes contact time when intermediate
activity level of disinfection required
• 1% chlorine compound (Clorox) diluted 1:5, 30 minutes contact time when
intermediate activity level of disinfection required

264
Noncritical items
• Contact intact skin only.
• Examples: blood pressure cuff, x-ray cone, stethoscope, lead apron
• Have a low risk of disease transmission.
• Some of these (x-ray cone & lead apron) should be precleaned and
disinfected or barrier protected.

265
Prevention of surgical wound infection
• Preoperative Phase:
Prophylactic antibiotic use
Preoperative mouth rinse
• Postoperative Phase

266
Principles of prophylactic antibiotic use
1. Procedure should have significant risk of infection.
2. Choose correct antibiotics

28
 3. Antibiotic plasma level must be high
4. Time antibiotic administration correctly
5. Shortest antibiotic exposure that is effective
Note 1: The antibiotic of choice for prophylaxis before oral surgery is penicillin or
amoxicillin. For patients allergic to penicillin, the best choice is clindamycin. The
third choice for oral administration for prophylaxis is azithromycin.
Note 2: When antibiotics are used prophylactically, the antibiotic level in the
plasma must be higher than when antibiotics are used therapeutically. The peak
plasma levels should be high to ensure diffusion of the antibiotic into all of the
fluid and tissue spaces where the surgery is going to be performed. For penicillin
or amoxicillin, this is 2 g; for clindamycin, 600 mg; and for azithromycin, 500 mg.

267
Procedure Should Have Significant Risk of Infection
• Size of bacterial inoculum
• Duration of surgery
• Presence of foreign body, implant, or dead space
• State of host resistance
Note: The usual surgical procedure performed in the mouth rarely involves
sufficient bacterial inoculation to cause infection unless an acute infection with
cellulitis or an abscess is already present.
The incidence of postoperative infection increases significantly with operations
lasting longer than 4 hours.

268
Timing in Prophylactic Antibiotic Use
• For the oral route, this is usually 1 hour; with the intravenous route, a much
shorter preoperative dosing interval is possible.
• If the surgery is prolonged and an additional antibiotic dose is required,
intraoperative dose intervals should be shorter (i.e., one half the usual
therapeutic dose interval). Therefore, penicillin and clindamycin should be
given every 3 hours during prolonged surgery.
• Evidence indicates that prophylactically administered antibiotics given 2
hours or more after surgery may increase the risk of wound infection.

29
269
Post-operative phase
• Cover surgical incisions with an appropriate dressing at the end of the
operation
• Use an aseptic non-touch technique for changing or removing surgical
wound dressings
• Do not use topical antimicrobial agents for surgical wounds that are healing
by primary intention.
• Chlorhexidine mouthwash is prescribed after each meal

271
Principles of support of the patient
• Management of postoperative pain
• Management of postoperative swelling
• Management of postoperative bleeding
• Prophylaxis to prevent infection.
• Postoperative oral hygiene must be kept to maximum.
• Adequate postoperative feeding should be maintained

272
Management of postoperative pain
1. Initiation of pain control
• The first dose of analgesic medication should be taken before the effects of
the local anesthetic subside. Its dose depends on the degree of trauma
received during the surgical procedure:
Simple surgery: Paracetamol 500mg
Complicated surgery: Paracetamol 5oomg + Oxycodone 10mg
2. Maintenance of pain control
• Mild pain situations: Ibuprofen 400-800 mg 4 hourly, Paracetamol 500-1000
mg 4 hourly
• Moderate pain situations: Codeine 15-60 mg, Hydrocodone 5-10 mg
• Severe pain situations: Oxycodone 2.5-10 mg

273

30
Uses of analgesia in pregnancy and lactation
• Paracetamol is the analgesic of choice in all stages of pregnancy.
• The use of NSAIDs, including aspirin, is less favorable, particularly late in
pregnancy.
• If paracetamol is insufficient, opioids are considered acceptable during
pregnancy provided they are given for a short duration.
Note: NSAIDs may predispose to ineffective contractions during labour, increased
bleeding during delivery or premature closure of the ductus arteriosus of the
heart. NSAIDs are therefore contraindicated in the third trimester.

274
Use of Analgesics for Pediatric Patients
• Aspirin is contraindicated for the young patient because it can potentially
induce Reye’s syndrome.
• Paracetamol, may be considered the drug of choice for the pediatric
patient.
• For pain of a higher level, either ibuprofen or codeine can be used, both
being available in an elixir form to facilitate administration.
Note: Reye’s syndrome is a potentially fatal disease of childhood., characterized
by sever increased intracranial pressure (due to cerebral edema), and liver
dysfunction.

275
Management of postoperative swelling
• Swelling usually reaches its maximum 36 to 48 hours after the surgical
procedure. Swelling begins to subside on the third or fourth day and is
usually resolved by the end of the first week.
• The ice bag should be kept on the local area for 20 minutes and then kept
off for 20 minutes, for 12 to 24 hours.
• On the second postoperative day, neither ice nor heat should be applied to
the face.
• On the third and subsequent postoperative days, application of heat may
help resolve the swelling more quickly.

31
276
Management of Postoperative Bleeding

Note: The gauze may be moistened so that the oozing blood does not coagulate in
the gauze and then dislodge the clot when the gauze is removed. The patient
should be instructed to bite firmly on this gauze for at least 30 minutes The
patient should be told that it is normal for a fresh extraction site to ooze slightly
for up to 24 hours after the extraction procedure. If the bleeding is more than a
slight ooze, the patient should be told
how to reapply a small piece of gauze directly over the area of the extraction. The
patient should be instructed to hold this second gauze pack in place for as long as
1 hour to gain control of bleeding. Further control can be attained, if necessary,
by the patient biting on a tea bag for 30 minutes. The tannic acid in regular tea
serves as a local vasoconstrictor.

277
Oral hygiene
• On the day of surgery patients may gently brush the teeth that are away
from the area of surgery in the usual fashion. They should avoid brushing
the teeth immediately adjacent to the site of surgery to prevent a new
bleeding episode, avoid disturbing sutures, and avoid inducing more pain.
• The next day, patients should begin gentle rinses with dilute salt water, or
0.2% chlorhexidine
• Most patients can resume their preoperative oral hygiene measures by the
third or fourth day after surgery.

32
 • Rinsing three to four times a day for approximately 1 week after surgery
may result in rapid healing.

278
Postoperative feeding
• The patient must have an adequate intake of fluids, usually at least 2 liters
• Food in the first 12 hours should be soft and cool. Cool and cold foods help
keep the local area comfortable.
• If the patient had multiple surgeries in all areas of the mouth, a soft diet is
recommended for several days after the surgical procedure. The patient,
however, should be advised to return to a normal diet as soon as possible.

THE END

Arranged by:
Dr. R. K. Al-Kamali
BDS, FDSRCSEd, FFDRCSI
Consultant Oral and maxillofacial Surgeon

33