OS Sheet #2 By Mustafa Alkhandak

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OS Sheet #2 By Mustafa Alkhandak

Post by Sura on 27/2/2012, 11:48 pm

http://www.4shared.com/file/nl2skVwH/OS_2.html
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Re: OS Sheet #2 By Mustafa Alkhandak

Post by Shadi Jarrar on 17/3/2012, 4:37 am

Oral surgery
Dr. Zyad Malkawi
Feb 13th
This subject is very important because every day or every other day you will face dental infection either in your private practice or your public one, so it’s very common more than anything else.
First I would like to start the lecture with my own experience case, last week we had a patient that was complaining from facial pain and trismus, he can’t open his mouth, so this subject is so important u might miss it easily, trismus can be as a result of dental infection in lower 6 for example. Some of you might think that how the patient had trismus and how it happened , so the idea of this lecture and the next one is to really direct your knowledge how to think and what to think about, so we have the oral cavity exactly you know what we mean by oral cavity(its what’s inside the mouth), the connection between the major borders , the lips ,skin of the face and the oral cavity. The oral cavity as simple as that we can see it inside when we do the diagnosis, we have teeth, soft tissues, oral mucosa that surrounds all the structures, even the tongue is considered as oral mucosa, it’s not only a muscle, it’s a muscle which is covered by oral mucosa, and we also have the periodontium so we have three main structures.
So the odontogenic infection is from two main things the first one is the dental tissues which is teeth , the second one is the periodontium , the effect of oral mucosa as a result of this infection, the infection happens in the dental tissues but we notice it in the oral mucosa, swelling, buccal face infection (it will be discussed later) but we are thinking about two main things , periodontium or teeth but the presence of the patient doesn’t necessarily have to be just a dental thing this is exactly the main way of thinking about odontogenic infection .
Now in the oral mucosa we have microorganisms present in all people, its presence is very important as you know there is homeopathic system between these bacteria (aerobic, anaerobic, fungal and all these things) so if any type of these bacteria or fungi became dominant, we will have problems. Our lecture today is about that the oral cavity, it has many organisms, mainly the infection causative ones are the anaerobes, in 1985 they did a survey in the United States on 404 patients and since that time we knew why we usually give flagin?? For example in dental infections most of you had their wisdom extracted and also had pericoronitis, now metronidazole is essential for anaerobic microorganism. So since 1985 (the 404 patients) they have been following these protocols , the aerobic was found on 28 patients just 7% im considering them like 5% (sorry bas el drhaik byeshra7) the anaerobic was on 133 patients 33% the mixed type 243 patients 60%. In fact its mainly anaerobic that’s why we give broad spectrum antibiotic , you know what I mean by broad spectrum , penicillin for example is a narrow spectrum antibiotic (very important) that’s why in children you have to use the narrow spectrum if possible if he had infection but what I care about is the principle when we think about the oral cavity, we think about the anaerobic and the mixed microorganisms but if it was a simple infection or the patient was a baby at the beginning of the infection ,he didn’t have fever or abnormal vital signs, we don’t give him augmentin 125mg for example, you’re not helping the patient by doing that. So the main idea of this lecture is how to think.
They did another survey and found out that aerobic consist of about 25% of population the gram+ 85% of the aerobic ones (the most common) and the streptococcus 90% from the 85% (gram+ ones) check out the handout. The anaerobic consist of about 75% this is what they found, gram+ 30% /gram – 4% /gram+ rods 10% /gram- rods 50% and miscellaneous 6%.
(mafhmtkteer 3al dr bas azon bas beddo ne7faz el asma2 bas ) but mainly this is how the natural history of progression of infection happens. As simple as that , the cause of dental infection usually is necrosis of the pulp & the cause of necrosis of the pulp is usually from dental caries (mainly start as aerobic bacteria) it’s like when you swim above the level of water u have oxygen but if you go underneath u don’t so u die here in the tooth, the anaerobic multiplies in deeper parts of the tooth but the necrosis consists mainly of anaerobic organisms but if you treat it if it was simple infection ,penicillin is most likely to be the choice, so always remember the narrowest spectrum the better antibiotic you give. Now after necrosis happens we’ll have bacteria and gases inside the pulp and also necrotic tissues ,so we are trying to find a way out so the bacteria either go upwards or downwards (we have food upwards so they most likely go downwards) causing periodontal pockets they its most likely that the patient comes with dental caries and periodontal pocket , this is the steps exactly , they reached the periapical tissues where the orifice or the canal or periapical foramen or the lateral canal they spread out from these points , afterwards it reaches the cancellous bone then they try to find a way out then it reaches the cortical bone (the narrowest part) because we have thick part and the narrow part , then it goes to the soft tissues, then at this point it does not necessarily go to the periapical region of that tooth, this is the main idea so the soft tissue infection depends on the ready perforated site.
Here the dr was giving us an example of a patient that had several surgeries and she also had a scar that was caused by a lesion on the cheek and every time the surgeon takes it away it comes back , once our dr looked in the oral cavity, he found a sinus discharge from the upper right 6 (pictures of the case will be shown next week) so the discharge was above the buccinators muscle ,the buccinators muscle is like a ring that surrounds the bone, so if the drainage is above the buccinators muscle there will be a face infection if its below that muscle there will be a sulcular infection and that will be intraorally.
Now if the discharge is above the buccinators muscle this more serious than if its below, as for the patient she had the discharge above that muscle so I inserted an instrument in the sinus and did an X-ray, you have to incise the whole sinus and do extraction of the cause which is the tooth , this was the treatment of the patient, so it depends on the opening.
Another patient that has a trismus, so we have something that is affecting the masticatory muscles of the mouth (lat+medpterygoid ,masseter,temporalis) so we are looking for submasseteric abscess so no swelling will be shown but when you check out his tempreture it will be around 39 he also had pus, blood pressure will also be high as well as the respiratory rate(normal=14-16) because there will be narrowing of the airway, so if we leave this patient he will die, this case will be discussed next week. So never underestimate dental infection although the majority of them are simple, many people died because of dental infection.
Vital signs are very important for diagnosis the patient might have high blood pressure with no high temp, in this case the patient is fine but if both were high then there is a proplem.
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Q.why does the temp increase?
(the recorder was not clear but what I heard is that because there will be a systemic defense)
The dr then asked about the difference between sterile inflammation and infection?
Infection has microorganisms like bacteria unlike sterile inflammation (zaylammatodrob wa7ad 3ala wejhoiza ma injara7 bekoon inflammation ammaizasarfe jare7had bekoon infection)

So the infection differs from the inflammation in the presence of bacteria and loss of function.
The location of odontogenic infection in the oral cavity from a specific tooth depends on : 1- thickness of the bone over the apex of the tooth ( upper anteriors usually have thinner buccal bone than palatally except for lateral ) 90% (upper lateral incisor the direction of the root is inclined palatally ) and the palatal root of the upper 6 so the thickness of the bone will be thinner palatally to lateral incisor, so if the patient came to your clinic with infection palatally you have to suspect with upper lateral anteriorly or if its posteriorly you have to think of upper 6 or 7 .(lower teeth from premolars to premolars have thinner labial bone than lingual and all of the anterior teeth are above the buccinator muscle so the infection will be in the labial sulcus except for upper canine which have long root and the apex is above levator angulioris ( canine space infection ) labially but it’s not shown in the sulcus , all what you will see is a patient with a closed eye and this situation is dangerous because the spread of infection from the canine space will lead to infection in the cavernous sinus . once you see a patient with a canine space infection you have to check his vital signs like temperature ( normal 36.5-37.5) if its 38.3 = 101 f , you have to admit the patient to the hospital or they will withdraw your license .

2- the relationship of the site of perforation to the muscle attachment of maxilla and the mandible , sometimes in upper premolars the buccinators muscle attachment is below the apex of the root so there will be buccal space infection (upper 6 ,7, 8 most offten will lead to buccle space infection , as for the lower molars it depends on the root that is infected. )
Lower 6 has thinner bone labially
Lower 7 , 8 have thinner bone linguallly
Mesial root of lower 6 is above the mylohyoid muscle attachment, distal root of lower 6 is below the mylohyoid muscle attachment so the infection will be in the submandibular space .
( submandibular space infection will be from 8 , 7 or distal root of 6 )
Sublingual space infection will be from mesial root of 6 and premolars or anterior teeth .
Ledwings angina is an infection of both submandibular and sublingual spaces
3- determine the severity of infection by : a – history of chief complaint(duration of pain to determine if its acute or chronic) you should read from the book about the difference between infection and cellulitis.
b-examination orally: for example if the patient has trismus you will notice that he can’t open his mouth, fistula or sinus.
c-general vital signs like temp: above 38.3, pulse rate :above 100, blood pressure: it will increase if patient is anxious or in pain, respiratory rate: above 18.
If these signs are mild, you can give him antibiotic, if its moderate to severe then you have to admit him to the hospital.
Then the dr started talking about the difference between cellulitis and abscess:
Cellulitis:
Acute (by duration), severe &generalized (as for the pain), large with diffuse borders(as for the size).
Abscess:
Chronic, localized, small with well circumscribed border, as for palpation its dough to indurated, there is no pus but there is serous fluid so we have to release pressure(Im not sure about that, check it out plz)
-the degree of seriousness of cellulitis > abscess(anaerobic)
Next lecture we will be talking about surgical treatment .
Done by Mustafa alkhandak
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Shadi Jarrar
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