Tip

Think: Pain, size, localization, palpation

• tapentadol can be prescribed but is not on dental PBS
• Hydromorphone is in dental PBS but extreme caution should be used
• Remember- codeine does not have an analgesic effect on everybody (consider pharmacogenomics)

*Note on Little people

• Asprin should not be given to children under 16 years as this riskes Reye's syndrome
• Childrens dosage depends on their weight

WISDOM TEETH

signs of ian involvement

• darkneing of roots, defelction of roots, changes to canala, jutapical area

Sedation

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Based on your oral surgery lecture and workshop notes, the indications and contraindications for the different types of anesthesia/sedation are structured as follows:

1. Minimal Sedation (Anxiolysis)

A. Inhalation Sedation (Nitrous Oxide / $N_2O$)

• Indications:

  • Fear and anxiety in patients.

  • Pain control or managing breakthrough pain when full local anesthesia is difficult to achieve.

  • Medical conditions that are exacerbated or triggered by stress.

  • Managing a sensitive gag reflex.

  • Traumatic or highly complex dental procedures (especially in posterior regions due to equipment setup).

  • It should be considered the first-line option for children requiring sedation.

• Contraindications:

  • Psychosocial Factors: Claustrophobic patients, severe anxiety, high complexity of dental treatment, or a lack of understanding of the process due to age or learning difficulties.

  • Medical Factors: Nasal obstructions or upper respiratory tract infections, COPD, ASA III, IV, or V (severe systemic disease), severe psychiatric disorders, and the first trimester of pregnancy (both for the patient and if staff pregnancy concerns exist).

  • Dental Factors: Upper anterior procedures due to equipment constraints.

B. Oral Sedation (Oral Benzodiazepines)

• Indications:

  • Dental anxiety (highly accepted and familiar option, commonly known as "Valium").

  • Short dental procedures lasting a maximum of 1 to 2 hours.

  • Can provide pre-operative night dosing to ensure restful sleep before a procedure.

• Contraindications:

  • Prolonged procedures.

  • Severe anxiety that has not been managed effectively with minimal sedation.

  • Severely limiting heart, cerebrovascular, lung, liver, or kidney disease.

  • Allergies or other adverse events related to drugs used in sedation, analgesia, or anesthesia.

  • Substance abuse.

  • Prior patient-reported inefficacy (e.g., patient states that temazepam, lorazepam, or diazepam have failed to work previously).

  • Must be used with caution in older, frail, or cognitively impaired patients, as well as patients with Obstructive Sleep Apnea (OSA).

  • Cannot be used if the patient does not have a responsible escort or carer to look after them post-procedure.

  • Limitation on Combining: Combining oral benzodiazepines with nitrous oxide constitutes moderate sedation, which is outside the general dental scope without additional formal postgraduate endorsement.

2. Intravenous Sedation (Moderate Sedation)

• Indications:

  • Effectively suppresses intense patient anxiety and patient distress.

  • Effectively suppresses a severe gag reflex.

  • Allows the operator to focus entirely on the dental procedure while a qualified sedationist/anaesthetist handles the airway and monitoring.

  • Generally well tolerated by patients for procedures like multi-tooth wisdom extractions.

• Contraindications & Limitations:

  • Patients who are not medically suitable or are unwilling/unable to pay the higher out-of-pocket costs.

  • Patients with an unmanageable airway risk (facilities must be prepared for moderate sedation risks, specifically potential airway compromise).

  • Cannot be performed if the clinic lacks the specialized equipment (like an AED, airway adjuncts, or capnography) or fails to meet the strict staffing requirements (at least 3 to 4 trained staff members must be in the room).

  • Procedures where the patient cannot comply with pre-procedural fasting.

3. General Anaesthesia (GA)

• Indications:

  • High procedural difficulty or when it is impossible to achieve adequate anesthesia using local anesthetic (LA) alone.

  • Extensive procedural length.

  • High level of unpleasantness associated with the procedure.

  • Patient preference (though practitioners must carefully balance patient preference against safety risks).

  • Indicated for patients requiring a clear surgical field (e.g., orthognathic surgery or Open Reduction Internal Fixation [ORIF]).

• Contraindications & Facility Acceptance Restrictions:

  • Day Surgery Exclusion Criteria (e.g., Southbank Day Surgery protocol):

    • Weight $\ge 130\text{ kg}$ (not negotiable due to table limits and manual handling occupational hazards).

    • BMI $> 40$ (or BMI 40–42 without high-level clinical governance approval) due to more difficult intubations and higher complication rates.

    • Presence of Obstructive Sleep Apnea (OSA).

    • Significant respiratory disease or anticipated airway difficulties.

    • Patients who are not normally ambulant with minimal assistance.

  • Patients who carry high systemic mortality risks (clinicians must protect patients from themselves regarding premature demands for GA for minor procedures).

  • If a patient is unsuitable based on these medical or physical limitations, they are contraindicated for day surgery and must be redirected via alternative public hospital pathways.

bone cysts and tumours

Based on your oral surgery workshop notes, here are the diagnoses (clinical/radiographic presentation) and treatments for the common jaw cysts and the ameloblastoma tumor.

1. Dentigerous Cyst

• Diagnosis (Pathogenesis & Presentation):

  • Mechanism: It is a developmental odontogenic cyst formed by fluid accumulation between the reduced enamel epithelium and the enamel surface of an un-erupted tooth.

  • Anatomy: It characteristically surrounds the crown of an impacted tooth, resulting in a presentation where the tooth crown is inside the cyst lumen and the roots remain outside. It is commonly associated with impacted teeth, such as lower second molars (e.g., tooth 47) or third molars.

• Treatment:

  • Surgical Enucleation: The standard treatment is surgical enucleation, typically accompanied by the extraction of the associated impacted tooth at the same time.

  • Marsupialization: Alternatively, the cyst can be marsupialized (exteriorized/turned inside out) to decompress the lesion. This relieves pressure, allowing bone to lay down and shrinking the cyst to a manageable size for later surgical removal.

  • Orthodontic Alignment: Following marsupialization, the associated tooth can sometimes be brought into alignment in the dental arch using an orthodontic appliance.

  • Surgical Exposure: Surgical exposure of the Cemento-Enamel Junction (CEJ) may be attempted to encourage natural eruption, though patients must be warned that the tooth may remain stationary.

2. Odontogenic Keratocyst (OKC)

• Diagnosis (Clinical & Histopathological Features):

  • Clinical/Radiographic Presentation: It has a wide age range (1–80 years, peaking between 10–30 years). On an OPG or CT scan, an OKC appears as a well-defined solitary radiolucency or as a multilocular, polycystic radiolucency (often seen in the mandibular angle/body). Note: Multiple OKCs are a key diagnostic feature of Gorlin-Goltz syndrome.

  • Definitive Diagnosis: Ultimate diagnosis relies entirely on histopathology. Histologically, an OKC uniquely features:

    1. A uniform lining of parakeratinized squamous epithelium (6–10 cells thick).

    2. Palisaded columnar or cuboidal basal cells.

    3. A corrugated layer of parakeratin on its luminal surface.

    4. A lack of rete pegs.

• Treatment & Prognosis:

  • Surgical Enucleation: The primary treatment is surgical enucleation.

  • Management of Recurrence: OKCs have a high recurrence rate of up to 30%. This high rate is caused by a very thin, friable lining that is easily left behind, as well as the presence of "satellite" or "daughter" cells in the cyst wall.

  • Factors that predict a high risk for recurrence include large size, cortical perforation, tooth involvement in the lumen, and daughter cysts.

  • To reduce recurrence, enucleation can be combined with adjunctive therapies such as peripheral ostectomy, cryotherapy, or the application of Carnoy’s solution.

3. Ameloblastoma (Benign but Locally Aggressive Tumor)

• Diagnosis (Clinical & Radiographic Presentation):

  • Clinical Presentation: This is the most common neoplasm of the jaws, originating from odontogenic epithelium. It is typically asymptomatic, benign, but locally invasive and aggressive. It most commonly forms in the posterior mandible.

  • Radiographic Presentation: It typically appears as a multilocular radiolucency often described as having a characteristic "soap bubble" appearance (though it can occasionally present as solid or unilocular). Unlike slow-growing benign cysts that displace teeth, aggressive tumors like ameloblastoma tend to resorb adjacent teeth and cause cortical expansion.

  • Imaging Workup: Comprehensive assessment requires an OPG for a panoramic view and a CT scan/CBCT to evaluate the cross-sectional bone involvement and proximity to vital structures for surgical planning.

• Treatment:

  • Conservative vs. Radical Intervention: Can be treated by curettage or radical excision/resection.

  • Radical Resection: Because the solid/multicystic type is highly locally aggressive with a high chance of recurrence, it often requires radical resection (removing the affected portion of the jaw with clean, appropriate margins to prevent recurrence).

  • Reconstruction: Following radical resection, complex jaw reconstruction is performed. This involves restoring the mandible using osteotomy techniques (such as fibula bone grafts), stabilized with surgical reconstruction plates and screws to maintain the patient's facial profile, mastication, and speech functions.