Essentials of Oral and Maxillofacial Surgery

M. Anthony Pogrel, Karl-Erik Kahnberg, Lars Andersson, M. Anthony Pogrel, Karl-Erik Kahnberg, Lars Andersson

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN: 9781405176231
• eBook ISBN: 9781118860809
• Edition: 1
• Topic: Medicine
• Subtopic: Oral Health & Surgery

Expert teaching in the fundamentals of oral and maxillofacial surgery

Essentials of Oral and Maxillofacial Surgery is the key textbook for all undergraduate dentistry students and trainees starting out in oral and maxillofacial surgery, oral surgery and surgical dentistry. Condensed and revised from the major reference work Oral and Maxillofacial Surgery, all revisions have been made by the editors in order to bring the text up-to-date and accessible for a student audience.

The book's coverage extends from basic principles such as patient evaluation, radiographic imaging, and surgical instruments, to specific conditions and procedures, from tooth extraction and endodontic surgery to trauma, implants, dentofacial deformities and orofacial pain. It also offers:

• A companion website with downloadable figures and MCQs to test your knowledge
• Over 600 colour photographs, radiographs and explanatory line drawings to illuminate the text
• Contributions from an international group of authors, distilled by an expert editor team

Part 1: Basic Principles

(Section Editor: Tony Pogrel)

Chapter 1
Patient Evaluation

The goal of preoperative evaluation is to reduce patient risk and the morbidity of surgery, and is based on the premise that it will modify patient care and improve outcome.

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) requires that all patients receive a preoperative anesthetic evaluation and the American Society of Anesthesiologists (ASA) has approved Basic Standards for Preoperative Care which outline the minimum requirements for a preoperative evaluation. Preoperative patient assessment is important in order to develop a safe and appropriate surgical and anesthetic plan.

Obtaining a Patient History

The importance of an accurate, detailed history cannot be overemphasized because it provides the framework on which the clinician builds an accurate diagnosis and treatment plan. An inaccurate or incomplete evaluation may lead to a delay in treatment, unnecessary testing, or misdiagnosis.

It is often helpful to review previous medical records. This can provide important information and save time during the interview process. The patient should be asked to describe the history of the present illness (HPI). Information should be gathered regarding onset, intensity, quality, location, duration, radiation, and any exacerbating or relieving factors. Constitutional symptoms that relate to the present illness should also be noted. Examples of pertinent positives and negatives with regard to the chief complaint may include fever, chills, loss of weight, weakness, etc.

The past medical history (PMH) alerts the clinician to any coexisting illnesses that may have an impact on any planned surgeries. A family history (FH) may reveal risk factors for patients as well as the possibility of inherited illnesses such as hemophilia or malignant hyperthermia.

The social history (SH) of a patient should include information regarding their social support system and also any habits such as tobacco, alcohol, or illicit drug use. These habits may adversely affect healing and also increase a patient's risk for undergoing a planned surgical procedure.

A review of systems (ROS) is a comprehensive method of inquiring about a patient's symptoms on an organ system basis. The review of systems may reveal undiagnosed medical conditions unknown to the patient.

Physical Examination

During the physical exam the clinician further reinforces or disproves impressions gained during the history-taking portion. Vital signs are recorded at the beginning of the physical exam. These include blood pressure, pulse rate, respiratory rate, and temperature. The patient's general appearance should be noted.

For a complete description of examination techniques the reader is advised to consult textbooks on physical diagnosis.

Comorbidities/Systemic Diseases

The clinician needs to assess potential risk factors and understand their effect on treatment. Changes in heart rate, rhythm, blood pressure, preload, afterload, and inotropy may occur during surgery and these can have deleterious effects, especially in patients with comorbidities. The risks for complications are greatest when caring for patients who are already medically compromised. Many significant untoward events can be prevented by careful preoperative assessment along with attentive intraoperative monitoring and support.

Cardiovascular System

Cardiac Disease

Cardiac complications following non-cardiac surgery constitute an enormous burden of perioperative morbidity and mortality. More than one million operations annually are complicated by adverse cardiovascular events, such as perioperative myocardial infarction or death from cardiac causes. Common cardiac risk factors include diabetes, hypertension, family history of heart disease, hypercholesterolemia, and obesity. Certain populations of patients, such as the elderly, diabetics, or women, may present with more atypical features.

Methods for evaluating a patient's cardiac risk preoperatively include a careful history, including exercise tolerance, physical examination, and electrocardiogram (EKG). Based on this information, various risk indices, guidelines, and algorithms can assist the clinician in deciding which patients can undergo surgery without further testing and which patients may benefit from further cardiac evaluation or medical therapy prior to surgery. Risk assessment involves evaluating patients' comorbidities and exercise tolerance, as well as the type of procedure to be performed to determine the overall risk of perioperative cardiac complications. Exercise tolerance is a major determinant of cardiac risk and need for further testing. Beta blockade has shown clear benefits in risk reduction whereas revascularization procedures, such as coronary artery bypass grafting, have not been shown to be useful in reducing non-cardiac surgical risk.

Hypertension

Hypertension is a common disease which can increase perioperative cardiac risk. Hypertension has been associated with an increase in the incidence of silent myocardial ischemia and infarction. The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recently revised their definition. Hypertensive patients with left ventricular hypertrophy are at a higher perioperative cardiac risk than non-hypertensive patients.

Controversy exists regarding whether to delay a surgical procedure in a patient with untreated or poorly controlled hypertension. Aggressive treatment of high blood pressure does diminish long-term risk. A study often quoted as the basis for delaying surgery for patients with a diastolic blood pressure greater than 110 mmHg actually demonstrated no major morbidity in that group of patients. Other authors have found little association between blood pressures less than 180 mmHg systolic or 110 mmHg diastolic and postoperative outcomes. Patients with severe hypertension are more prone to perioperative myocardial ischemia, ventricular dysrhythmias, and lability in blood pressure. For patients with blood pressures greater than 180/110 mmHg there is no absolute evidence that postponing surgery will decrease the cardiac risk. For patients without end-organ changes, such as renal insufficiency or left ventricular hypertrophy, it may be appropriate to proceed with surgery. However, patients with a markedly elevated blood pressure and new onset of a headache should have surgery delayed for further medical treatment. Patients with hypertension may have a contracted intravascular volume and therefore have an increased susceptibility to vasodilator effects of commonly used sedative and anesthetic agents. For elective surgery it is best to have the patient's blood pressure optimized prior to surgery.

Risk factors for hypertension include smoking, hypercholesterolemia, increasing age, family history of cardiovascular disease, and diabetes. Untreated hypertension commonly causes coronary heart disease, cardiomegaly, congestive heart failure, and end-organ damage. When evaluating a patient with hypertension, it is im...

Table of contents

• Cover
• Table of Contents
• Title page
• Copyright page
• List of Contributors
• Preface
• About the companion website
• Part 1: Basic Principles
• Part 2: Dentoalveolar Surgery
• Part 3: Implant Surgery
• Part 4: Oral Pathologic Lesions
• Part 5: Trauma
• Part 6: Dentofacial Deformities
• Part 7: Temporomandibular Joint Disorders
• Index
• End User License Agreement