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spasmodic movements of the head, body, and limbs. Forcible jaw closing, rolling of the eyes upward or to the side, and pinkish froth from the mouth are also noted. Breathing may stop, the face becomes cyanotic, and fecal and urinary incontinence may occur. The convulsions then cease and, after a deep breath, the postconvulsion phase follows, which is characterized by disturbances of the consciousness state, pallor, and weakness. This phase has variable duration and may last 10–30 min, with the risk of airway obstruction by mucous secretion, vomit, or the tongue falling posteriorly against the posterior pharyngeal wall. After the epileptic seizure, the patient regains consciousness, but feels exhausted and may have a headache, but does not recall the seizure itself.
Certain epileptic patients may present with status epilepticus, which is characterized by repeated seizures lasting more than 30 min, without a recovery period. This condition is a medical emergency, because there is not enough time for the patient to breathe normally and to recover from the stress of the first seizure. The same problem exists when the seizure is prolonged and lasts for more than 10 min.
The preventive measures recommended for avoiding seizures during dental procedures in an epileptic patient are:
ΟReduction of stress (e.g., with appropriate anxiolytic medication)
ΟAdministration of small amounts of local anesthetic and always after preliminary aspiration (excessive amounts, especially intravascularly, may precipitate convulsions)
ΟShort appointments, as painless as possible
ΟAdditional anticonvulsant drugs before the surgical procedure, always after consultation with the treating physician
1.27
Diseases of the Skeletal System
The main diseases of the skeletal system that the dentist must be aware of are: osteogenesis imperfecta, Marfan’s syndrome, cleidocranial dysplasia, Down’s syndrome, osteoporosis, idiopathic histiocytosis (formerly known as histiocytosis X), Gaucher’s disease,
Paget’s disease, osteopetrosis, fibrous dysplasia of the jaws, and encephalotrigeminal angiomatosis (Sturge– Weber syndrome).
Because of the compromised substrate of the jawbones, there is risk of fracture even during a simple extraction and, in certain cases, hemorrhage and delayed healing due to potential postsurgical infection.
The aforementioned syndromes may be accompanied by heart disease, therefore these patients need special care when surgery is to be performed. Depending on the severity of the disease the necessary precautionary measures can be:
ΟEmergency surgical procedures performed only
ΟAvoidance of abrupt awkward manipulations during extraction
ΟLocal measures to control bleeding when serious hemorrhage may result (Gaucher’s disease, Paget’s disease, Marfan’s syndrome, encephalotrigeminal angiomatosis)
ΟProphylactic administration of antibiotics to avoid development of infection in osteogenesis imperfecta, Down’s syndrome, osteoporosis, osteopetrosis, and Marfan’s syndrome
1.28
Radiotherapy Patients
Patients who have been treated recently with irradiation in the facial and neck area for therapeutic purposes present with increased risk of developing extensive bone infection if a tooth extraction or other surgical procedure in the mouth is performed. To avoid such a complication, the surgical procedure must be cautiously performed, after at least a year has passed without symptoms following the last radiotherapy session and the patient is given large doses of prophylactic antibiotics for several days. Wound closure is obligatory.
It is worth noting that when the extraction is performed before radiotherapy, 7–10 days must pass before the wound heals and radiotherapy begins. This period may be prolonged, depending on the patient’s condition and the administered radiation dose.
1.29 Allergy
An allergic reaction, either during or after any dental procedure, is one of the most serious problems a dentist may encounter.
Drugs and other substances that may evoke allergic reactions are: local anesthetics, antibiotics, analgesics, anxiolytic drugs, as well as various other dental materials or products.
Local Anesthetics. Allergy that is caused by the use of local anesthetics is usually due to the preservatives in the ampoule, which act as germicides. The most
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common preservatives used are the derivatives of paraben (methyl-, ethyl-, propyl-, and butyl-paraben). Today, most local anesthetics do not contain preservatives so as to avoid allergic reactions, resulting in a shorter shelf-life of the anesthetic solution.
Antibiotics. The antibiotic that interests the dentist most (as far as allergy is concerned) is penicillin, because it is considered the antibiotic of choice in most cases of dental procedure. The frequency of allergic reactions due to use of penicillin ranges from 2% to 10% and reactions manifest as mild, severe, or even fatal.
Analgesics. The analgesics that may be responsible, though infrequently, for allergic reactions are narcotics (codeine or pethidine), and acetylsalicylic acid (aspirin). Of the analgesics, aspirin is considered the drug responsible for most allergic reactions, which range from 0.2% to 0.9%. Allergic reactions due to aspirin vary from simple urticaria to anaphylactic shock.
Sometimes symptoms of asthma or angioneurotic edema may appear.
Anxiolytic Drugs. Barbiturates are the anxiolytic drugs that cause allergic reactions most frequently. The people usually affected are those who report a history of urticaria, angioneurotic edema, and asthma. Allergic reactions are usually mild and are often limited to the appearance of skin reactions (urticaria).
Various Dental Materials or Products. Acrylic resins, certain antiseptics, radiograph processing solutions, and gloves may evoke allergy. Allergic reactions are usually mild and present with stomatitis (inflammatory erythema) and skin urticaria.
1.29.1
Classification of Allergic Reactions
Allergic reactions, based on the immunological mechanisms that cause them, are classified into four types:
a.Type I reaction (anaphylaxis)
b.Type II reaction (cytotoxic hypersensitivity)
c.Type III reaction (immune-complex-mediated hypersensitivity)
d.Type IV reaction (cell-mediated or delayed-type hypersensitivity)
1.29.2
Types of Allergic Reactions
The clinical manifestation of allergy is not always the same. Depending on the body’s reaction, clinical symptoms appear whose seriousness varies from a simple rash to a medical emergency. These include:
Anaphylaxis. This is the most dangerous type of allergic reaction, which may cause the death of the patient within a few minutes. It involves acute respiratory and circulatory collapse, which presents with hoarseness of voice, dysphagia, anxiety, rash, burning, painful sensation, pruritus, dyspnea, cyanosis of the limbs, wheezing due to bronchospasm, vomiting, diarrhea, rapid irregular heart rate due to hypoxia, hypotension, and loss of consciousness. Anaphylaxis may prove fatal within 5–10 min.
Urticaria. This is the most common type of allergic reaction and is characterized by the appearance of vesicles of various sizes, which are due to the secretion of histamine and serotonin, resulting in an increased permeability of vascular structures. The vesicles induce pruritus and a burning sensation on the skin. The reaction may be limited or spread over the whole body. A severe reaction may cause a fall in blood volume and, as a result, anaphylaxis.
Angioneurotic Edema (Quincke’s Edema). This appears suddenly, and is a well-defined swelling of the soft tissues, especially the lips, tongue, buccal mucosa, eyelids, and epiglottis. The patient’s life is in danger because of obstruction of the upper respiratory tract, resulting in dyspnea and difficulty in swallowing, which, if not treated immediately, leads to death rapidly.
Allergic Asthma. This may appear as an isolated allergic reaction and presents as bronchospasm and respiratory dyspnea.
The most common precautionary measures that must be taken if a patient cites a history of any type of allergy are:
ΟQuestions about the type of allergy and the drug or substance that caused the reaction.
ΟReferral of the patient to an allergist for testing, if the history shows allergy to local anesthetics in the past.
ΟAvoiding the administration of drugs to which the patient presents hypersensitivity. For example, in
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the case of aspirin allergy, acetaminophen (Tylenol) may be prescribed, or in the case of allergy to penicillin, a macrolide may be administered.
ΟPatients with a history of atopic diseases, such as allergic rhinitis, asthma, and eczema, should be given particular consideration and attention.
ΟThe dentist should be prepared to deal with an allergic reaction with drugs (adrenaline, hydrocortisone, antihistamines, and oxygen).
1.30 Fainting
Fainting is the sudden, but temporary loss of consciousness, where the functions of the cortex of the brain are inhibited, resulting in lack of communication of the patient with their surroundings. This condition is the most common complication encountered in dentistry and may occur in all persons regardless of age. It is usually seen between the ages of 15 and 35, especially males.
The most common causes of fainting are emotional states, severe pain, orthostatic hypotension, and hormone disorders.
The first symptoms of fainting include headache, feeling of anxiety, pallor of face, perspiration, tachycardia, weakness and malaise, increased temperature in the area of face and neck, nausea, vertigo, and imbalance. As fainting progresses, pupil dilation, yawning, and hyperpnea, as well as cold limbs may be noted. Blood pressure drops and just before loss of consciousness, there is bradycardia after the initial tachycardia, diminishing of eyesight, and severe dizziness. Lack of response to sensory stimuli and lack of protective reflexes characterize loss of consciousness. The patient may present with an irregular or regular respiratory rate, while total apnea rarely occurs. Bradycardia (50 beats/min), a drop in blood pressure, short but mild convulsions (especially when the patient is in a sitting position), and muscle relaxation, which may cause obstruction of the upper respiratory tract (tongue falls posteriorly against the posterior pharyngeal wall), also occur. Loss of consciousness does not usually last longer than 10–20 s. If the fainting episode lasts longer than 5 min, then the possibility that it has a more serious cause is greater, whereupon transferring the patient to a hospital is necessary.
Fainting episodes may be avoided most of the time, if the necessary precautionary measures are taken:
ΟDetailed medical history. What has to be evaluated is the patient’s predisposition to fainting spells and if they are in a position to be subjected to the physi-
cal and psychological stress involved in a dental procedure. If it is ascertained that the patient feels extreme fear and anxiety or if factors that may precipitate a fainting episode are warranted, then sedative premedication must be administered, or, if possible, nitrous oxide–oxygen administered.
ΟAvoid causing pain. Before the administration of local anesthetics to very sensitive people, topical anesthetics should be used at the site of injection and deposition of the solution in the tissues should be as slow as possible.
ΟPlacing the patient in an appropriate position. Chair position of the patient is very important in preventing fainting episodes. Regardless of the site of anesthesia and the surgical procedure in general, the patient must be in a semi-supine or supine position, because in this position (particularly supine), ischemia of the brain does not occur and, therefore, neither does the fainting spell.
1.31 Pregnancy
Pregnancy is not a disease, but a normal state of a woman’s body; however, special treatment is required when the woman is about to undergo dental surgery, so that the developing embryo and the mother herself are not at risk. The most important risks are noted in the first trimester, because every intervention that may cause hypoxia may have a harmful effect on the embryo or be responsible for spontaneous abortion.
Therefore, during the first and second trimesters, every surgical procedure in pregnant patients who cite previous spontaneous abortions in their history should be avoided. If, however, an emergency arises (e.g., acute dentoalveolar abscess), the patient should be managed after consultation with her obstetrician. During the second trimester, the patient with a prob- lem-free history is not at risk, provided that the surgical procedure is short and as pain-free as possible. As far as the third trimester is concerned, every procedure should be avoided in the last days of pregnancy, because of the possibility of the baby being born during the dental procedure.
In all cases the patient’s obstetrician should be consulted, who will determine if anxiolytic, analgesic, and antibiotic drugs are necessary, especially if the pregnant patient presents with systemic diseases that may render management in a hospital setting necessary.
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Chapter 2
The maxillofacial area presents exceptional difficulties as far as the radiographic examination is concerned. Even so, this examination is the most valuable and important diagnostic tool for oral surgeons, who have to chose the most appropriate radiographic technique among many, so that the information they gather will help them significantly in diagnosis and therapy. It is obvious, of course, that radiographs are taken only if necessary for diagnostic purposes and after meticulously scrutinizing the patient’s history and the clinical examination of the patient.
Conventional radiographs are two-dimensional images, which depict three-dimensional anatomical areas. Therefore, correct interpretation of the radiographs is very important in diagnosing problems of the oral and maxillofacial area, and is achieved when:
ΟThe radiographs are of good quality.
ΟThe technique used for the various radiographs is known.
ΟThe entire area that interests us is depicted.
ΟWe are aware of the anatomy of the area and how various anatomical structures are depicted on radiographs.
ΟWe are well aware of the various pathologic lesions that may present in the area and how they are depicted radiographically.
The diagnostic information obtained from a radiograph depends on the quality of the radiograph; the higher the quality of the image, the greater the probability of an accurate diagnosis.
Some pathologic conditions may require an increase or decrease of the technique factors involved in developing a radiograph. This is due to the pathologic lesion itself. When the lesion enhances bone density, the technique factors must increase. In contrast, when the lesion causes a decrease in bone density, then the technique factors decrease.
Generally, the main indications for radiographic examination are:
ΟDiscovering a correlation between pathologic lesions and normal anatomical structures, e.g., the
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maxillary sinus, mandibular canal, nasal fossa, mental foramen, etc.
ΟDiscovering impacted and supernumerary teeth, root remnants, etc.
ΟEvaluation of the degree of radiopenetration of a lesion.
ΟIdentification of a lesion and its size, shape, and boundaries.
ΟThe development of a lesion.
ΟThe effect of a lesion on the bone cortex and the adjacent teeth.
The main radiographic techniques used in oral surgery are the following:
ΟPeriapical projection.
ΟOcclusal projection.
ΟPanoramic radiograph.
ΟLateral oblique projection of mandible.
More rarely, other extraoral projections of the face and jaw may be used, depending on the situation.
Periapical projections are advantageous in that they provide detailed information about the bone structure and aid us in the study of teeth that remain in the maxilla and mandible.
Occlusal projections have the same advantages as periapical radiographs, but they also depict larger areas. These projections provide the third dimension, used in conjunction with periapical or panoramic radiographs. They are also used for evaluating the arch of the jaw, bone quality and for examination of the greatest buccolingual dimension of the mandible.
A panoramic radiograph provides us with valuable information concerning the bone and its correlation to the mandibular canal, the maxillary sinus, and the nasal fossa. It also gives us an overall assessment of the dentoalveolar system and allows us to study the existing teeth, as well as the presence of bony lesions, root remnants, impacted teeth, etc.