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The Wonderful World ofOral Surgery

Jay B. Reznick, D.M.D., M.D.Diplomate, American Board of Oral and Maxillofacial Surgery

Tarzana, California

DentalTown

2nd Annual GatheringMarch 27, 2004

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Introduction

• Joined DT in August 2003• GPs discussing Oral Surgery topics• Minimal input from Specialists• Great thirst for knowledge about

implants, extractions and other office procedures

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TRAINING

4 years Dental School4 years Dental School4 years Hospital Residency4 years Hospital Residency

–– AnesthesiaAnesthesia–– Surgery (General and Subspecialties)Surgery (General and Subspecialties)–– Internal MedicineInternal Medicine–– Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery

Medical DegreeMedical Degree

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Today’s Goals

• Typical GP’s training in Oral Surgery consists of:– 1-3 weeks in Dental School Clinic– 1 week Hospital rotation

• GPR?• Military?

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Topics

• Come directly from the DT Message Boards– Medical History

• How does this affect your treatment plan.– Anticoagulants– Antibiotic prophylaxis

• How does your treatment affect the medical condition.

– Surgical extractions and impactions• When / whether to extract third molars• Consents• Surgical handpieces

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Topics

– Surgical extractions and impactions• Post-op instructions• Management of common post-op

complications

– Biopsy• Indications• Basic Techniques

– Management of Infections

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Let’s Begin!

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Medical History

• Hypertension• Cardiac disease• Pulmonary disease• Diabetes• Anticoagulants• Antibiotic

premedication

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Hypertension• Definition

– Systolic > 140– Diastolic > 90

• Medications– Beta-Blockers

• metopropol, labetolol, atenolol, propranolol– Ca++ channel blockers

• Verapamil, captopril, diltiazem– ACE Inhibitors

• Accupril, Atacand, Avapro, Cozaar– Diuretics

• Hydrochlorothiazide, furosemide

• RisksJBR

Hypertension

• Patients with well controlled BP can be managed like a normal patient

• Do not discontinue BP meds before procedure

• Epinephrine use• BP> 160/100: refer to MD before tx• DBP> 120: refer to ER

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Cardiac Disease

• Coronary Artery Disease (CAD)• CHF• Dysrhythmias• Valvulopathies• Prosthetic valves• Pacemakers/ ICD• Post-MI

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Congestive Heart Disease

• Due to prolonged hypertension, valvulopathies, impaired myocardial contractility

• Symptoms– Dyspnea– Orthopnea– Paroxysmal nocturnal dyspnea– Pitting ankle edema

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CHF

• Treatment:– Correction of reversible causes- HTN, valvular

dz, anemia– Diuretics– Digitalis– Vasodilators– ACE inhibitors

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Pacemakers

• Antibiotic prophylaxis not required

• Electrocautery can cause transient or permanent changes in function.

• Bipolar cautery OK

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ICD- Implanted Cardiac Defibrillator

• Antibiotic prophylaxis not required

• Presence of ICD is not a risk in itself

• Electrocautery can cause malfunction- bipolar OK

• Discharge of ICD is not harmful to caregivers in contact with patient

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Post-MI Dental Treatment

• Risk is of re-infarction• Greatest in first 6 months post-MI• “Emergent” dental treatment can be done as early

as 7 days post-MI• Medications

– Beta-blockers – Nitrates– Calcium channel blockers– Aspirin

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Post-MI

• Treatment goal is to reduce stress (tachycardia)

• Oral benzodiazepine plus nitrous oxide• Prophylaxis with nitroglycerine is

controversial

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Pulmonary Disease

• Asthma• COPD

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Asthma

A disease marked by recurrent dyspnea caused by episodic

bronchoconstriction.

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Patient Assessment

• Frequency of attacks• Precipitating factors• Duration of attacks• Management of attacks

– ER visits– Hospital admissions

• Current prevention therapy

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Classification of Asthma

• Mild intermittent- <2 attacks/wk; <2 noct attacks/mo

• Mild persistant- 2 attacks/wk; 2 noctattacks/mo

• Moderate persistent daily and nocturnal symptoms

• Severe persistent continual daily and nocturnal symptoms

Severity

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Asthma Treatment

• Bronchodilators- prn• Low-dose steroid inhalers; cromolyn;

leukotriene modifier• Medium-dose steroid inhaler, Beta-2

agonist inhaler; leukotriene modifier• High-dose steroid inhaler, long-acting

B-2 agonist inhaler; systemic steroids

Severity

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Dental Considerations

• Defer treatment until asthma is controlled• Keep inhaler available for acute attacks• Manage possible adrenal suppression (if

taking corticosteroids)• Stress reduction• Avoid erythromycin if using theophylline.

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COPD

• Affects 16 million people in US• Usually caused by smoking• Obstruction of airflow• Classified as

– Chronic bronchitis– Emphysema

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Chronic Bronchitis

• Hypersecretion of mucous

• Impaired ciliaryclearance

• Airway diameter is reduced due to inflammation

• Daily cough and sputum• Poor prognosis• “ Blue bloaters”

Emphysema

• Destruction of alveolar sacs - enlarge and coalesce

• Airways inflammed and narrowed

• Loss of elastic recoil-airway collapse during exhalation

• “Pink puffers”

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COPD

• Medications– Bronchodilators– Corticosteroids– Anticholinergics– Oxygen– Antibiotics

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Smoking Cessation and Surgery

• Effects on oxygen carrying capacity and cardiac function are short-lived

• Pulmonary complications and wound healing improve after 8 weeks of smoking cessation

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COPD

• Sedation with oral benzodiazepines OK• Respiration- O2 driven• Nitrous oxide can cause pneumothorax by

causing bullae to enlarge and rupture.

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Diabetes

• Type I (IDDM) “juvenile”àInsulin-Dependent

• Type II (NIDDM) “adult onset”àNon-Insulin-Dependent

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Complications of Diabetes

• Renal disease• Retinopathy• Neuropathies• Peripheral vascular disease• Cardiovascular disease

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Treatment

• Diet and weight loss• Hypoglycemic agents (sulfonureas, biguanides)• Thiazolidinedione therapy (Troglitazone)-

receptor regulation• Alpha-glucosidase inhibitor (acarbose)- slows

digestion and absorbtion of dietary carbohydrates• Insulin

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Insulin

• Lispro, Aspart : onset 5-15 min; peak 1-2h; duration 4-6h

• Regular insulin: onset 30-60 min; peak 2-3h; duration 6-8h

• NPH, Lente: onset 2h; peak 12h; duration 24h

• Ultralente, glargine: onset 6-8h; peak 16-24h; duration 36h

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Patient Evaluation

• Control of diabetes– Hgb-A1c

• Medications• Hospitalizations• Secondary diseases

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Diabetes- Precautions

• Insulin-Dependent Diabetics– Increased risk of infection and delayed wound

healing– Always cover with antibiotics

• Non-Insulin-Dependent DiabeticsIf well-controlled…– No increased risk of infection and delayed

wound healing

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Anticoagulants

• Coumadin (warfarinsodium)– Competitive

inhibitor of Vit. K-dependent clotting factors

– PT– 36 hour half-life– Prosthetic valves,

DVT, MI, stroke, A-fib, unstable angina

•Aspirin–Platelet adhesion-TxA2 (irreversible)

–Bleeding time–MI, stroke prophylaxis

•Plavix(clopidogrelbisulfate)

–Inhibits platelet aggregation- ADP

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Prothrombin Time (PT)

• Measures Vit. K- dependent clotting pathway (II, VII, IX, X)

• Tissue thromboplastin and calcium are added to citrated patient’s blood

• Rate of clotting varies with type of tissue thromboplastin added

• Human – most sensitive

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INR

• International Normalized Ratio• Recommended by WHO to

standardize coumadin tx• Previous recommendation for PT was

1.5-2.5 X nml• Therapeutic range for INR: 2.0 – 3.5• In the U.S.: INR 3.0 ≅ PT 1.6 x

control (normal = 1.0)• Used since 1983

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It is now recommended

that patients be left on

anticoagulants for minor

procedures if at risk of

thrombosisJADA November 2003

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Coumadin Therapy

Coumadin Therapy can usually be maintained if

INR is 3.5 or less

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Coumadin Therapy

• For major procedures, patient can be taken off coumadin starting 3-5 day before surgery

• LMWH (enoxaparin- Lovenox) given SQ-BID until 12h before surgery, and resumed in the PM

• Coumadin is restarted after surgery until INR is therapeutic

• Traditional “heparin window” recommended for prosthetic valve patients

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Other “Blood Thinners”

• Trental - pentoxifylline• NSAIDs• ASA• Plavix (clopidogrelbisulfate), Ticlid

(ticlopidine)

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To Do Surgery?• What is your experience/ comfort

level• “Hassle factor”• 15/30 minute time limit• Dealing with complications

– Backup

• GP doing surgery is held to the same standard of care as a specialist

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To Do Surgery?

• Just because you have an opening in your schedule doesn’t mean you should not refer the patient.

• Everything you do in your office should be a “practice builder”

• Referring the patient to the right specialist makes you look great to the patient

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Dentoalveolar Surgery

• Extractions– Non-Surgical– Surgical– Impactions

• Alveloplasty

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Strategy

• Mentally visualize the procedure from start to finish

• Anticipate what instruments will be needed, and have them ready/ readily available

• Headlight, loupes• Anticipate complications• “Measure twice, cut once”

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Exodontia Surgical Setup

• Local• Retractor(s)• Mouth prop• Scalpel• Periosteal elevator• Tooth elevator(s)• Universal forcep• Curette• Hemostat(s)• Suction tip(s)• Needle holder/ suture• Scissors• Gauze

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Local Anesthesia

• Septocaine (articaine)– Greater fat -solubility

than lidocaine– Better bone

penetration – Increased nerve

toxicity??

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Septocaine

My Recommendations:– Use for infiltration

• Maxillary- buccal/ palatal• Mandibular

– Avoid giving mandibular/ lingual blocks

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Surgical Extractions

My Routine:• Peridex• NSAIDs

– Lodine 400mg– 30 min preop

• Antibiotics

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Surgical Extractions

• Flap design• Handpiece• Root sectioning• Root retrieval• Suturing the site

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Surgical Flaps

• Purpose of flap is to gain access to surgical site, to obtain adequate visualization of field and avoid trauma to soft tissues.

• Avoid doing surgery “blindly”• Have a low threshold to lay a flap

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Surgical Flap Design

• Should be based on anatomy, blood supply

• Base broader than apex

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Surgical Flap Design

• Flap should be broader at base

•Size of flap depends on purpose

•Releasing incision

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Surgical Flap

• Sulcular incision to begin flap

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Extraction Instruments

• Elevators• Periotomes• Forceps• Handy-Dandy instruments

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Elevators

• Used to – Luxate teeth

• Try to luxateagainst bone

• Avoid excessive pressure on adjacent crowns

– Elevate roots

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Elevators

• Used to – Luxate teeth– Elevate roots

• My favorite: 46R– Beveled tip– Serrated edge

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Elevators• Scoop

– Upper 3rds– Separate tuberosity

from distal of tooth

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Periotomes• Very thin elevators

used to sever the PDL attachment of the tooth.

• Atraumaticextractions in the “Esthetic Zone”

• Minimal flap

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Periotomes

• Instrument blade is placed parallel to root

• Advanced down PDL space

• May take time

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Extraction Forceps• Universal forcep (62,

151) works 90% of the time

• Grasp the tooth as far apically on the root as possible– Rotate– Luxate– Figure-8

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Extraction Forceps

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Tooth Grabber

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Surgical Handpiece

• Allow sectioning of tooth and removal of bone

• Does not allow air to vent into the surgical field

• Subcutaneous emphysema

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Subcutaneous Emphysema

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Surgical Handpieces

• Straight vs. angled• Burs- fissure vs. round

701701 702702 703703

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Angled Surgical Handpiece

• Impact-Air 45– 45 degree head– Air exhausted to rear– 400-500K RPM– Fiberoptics– $700

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Straight Surgical Handpiece

• Air/ N2 driven, rear exhaust

• Electric• 100K RPM• High torque• $5000

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Surgical Extractions

• Single-Rooted Teeth• 2-Rooted Teeth • 3-Rooted Teeth

• If the tooth does not move with an elevator and forcep, get out the handpiece!

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Single-Rooted TeethMaxillary/ Mandibular Anteriors

•Atraumaticextraction desireable

•Want to minimize flap reflection and bone removal

•Periotomes are ideally suited for this task

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Two-Rooted Teeth

• Bicuspid/ Premolar• Mandibular Molars

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Three-Rooted TeethMaxillary Molars

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Root Retrieval

• Root tip elevators

• Root tip forceps– Steiglitz

• A neat trick

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Alveoloplasty

• Multiple adjacent teeth• Removal of interdental bone, and

contouring of ridge• Eliminate sharp edges, sore spots

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Alveoloplasty

• Rongeur• Bone File• Rotary instruments

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Suturing

• To reapproximatesurgical flaps

• To hold packing in place

• A suture alone does not hold the blood clot in place.

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Suture

• Size§ 3-0: basic§ 4-0: finer

• Type§ Silk§ Gut§ Plain§ Chromic

§ Vicryl (PGA)

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Closure of Multiple Adjacent Extraction Sites

Transposed Papillae Closure

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Ridge Preservation Grafting

• Optimizes the amount of bone present at extraction site

• Reduces early (1st 6 months) ridge resorbtion by about 75%

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Ridge Preservation Grafting

• After extraction socket is debrided and irrigated, graft material is packed into socket

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Third Molars

• Lots of controversy• Patient health vs. $$$• Many different viewpoints• Any third molar that has not/will not come

into complete, functional occlusion, and can be easily maintained by the patient, should be removed.

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Wisdom Teeth

• Periodontal issues• Best time: roots 50% -75% developed

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Wisdom Teeth

• Periodontal issues• Best time: roots 50% -75% developed• Earlier is better than later• “It’s downhill after 25”• > 35 years old, the benefits must outweigh

the risks

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Third Molars• Classification- Gregory and Pell

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Classification- By PositionMesioangular

Vertical

Distoangular

Horizontal

Deep

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Classification- Procedure Code

• Surgical - fully erupted, may need bone removal and/or sectioning

• Soft Tissue Impaction - covered only by gingiva, may need bone removal and/or sectioning

• Partial Bony Impaction - bone covering crown up to 50% (radiographically), willrequire bone removal and/or sectioning

• Full Bony Impaction - bone covering crown greater than 50% (radiographically), willrequire bone removal and/or sectioning

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Radiographs- 3rd Molars

• Should show present clinical condition• Must show roots completely• Must show relationship of roots to

sinus (upper)• Must show relationship of roots to IAN• Panoramic - ideal

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Factors That Make Impaction Surgery…

Less Difficult:– Mesioangular impaction– Soft tissue impaction– Adequate A-P room– Superficial depth– Fused conical roots– Separated from 2nd molar– Separated from IAN– Roots 1/3 to 2/3 formed– Wide PDL– Large follicle– Elastic bone

More Difficult:– Distoangular– Full bony impaction– Tight A-P space– Deep– Curved, divergent roots– Contact with 2nd molar– Close to IAN– Long, thin roots– Fully-formed roots– Narrow PDL– Thin follicle– Dense, inelastic bone

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Risks of Third Molar Removal

• The Usual– Bleeding– Swelling– Pain– Infection– Dry socket– Delayed healing

•Nerve Injury- “numbness”

•Mandible Fracture

•Oral-Antral Fistula

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Mandibular Nerve

• Radiographic Relationship of Mandibular Canal to Tooth Roots– Risk of paresthesia/ nerve injury

• Superimposition (no contact)• Grooving of root by IAN• Perforation of root by IAN

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Lingual Nerve

• Very variable location• May be above or

below the mylohyoidmuscle

• Avoid lingual retraction and instrumentation

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Risks of Not Removing 3rds

• Pericoronitis• Severe infection• Damage to bone and/or adjacent teeth• Cysts/ Tumors• Jaw fracture• It may need to be removed later

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Third Molar Impactions• Visualize procedure

from start to finish• Have instruments

available• Adequate flap to

visualize target and minimize soft tissue trauma

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Lower 3rd Molar Incisions

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Upper 3rd Molar Incisions

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Bony Exposure• Sweep away bone• The tooth crown is

harder than bone• Let the bur “drive”

itself• Light pressure• Fully expose furcation

to facilitate sectioning

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Third Molar Extractions• Vertical

impactions– Expose crown– Try elevating– Bisect crown– Deliver

• Distal half• Mesial half

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Third Molar Extractions• Mesioangular

impactions– Expose crown– Bisect crown– Deliver

• Distal half• Mesial half

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Third Molar Extractions• Horizontal

Impactions– Expose crown– Section/ remove

crown– Section/ deliver

roots

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Third Molar Extractions• Distoangular Impactions

– Most difficult impaction

– Section/ remove crown

– Deliver roots• Crane pick• Cryer

– Pray a little

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Typical Case: 4- 3rd Molars

• Peridex BID, starting 2 days before surgery

• General Anesthesia

• Lodine 400mg• No routine

antibioticsJBR

Informed Consent

• A discussion with the patient of the potential/expected-– Risks– Benefits– Complications– Alternatives, including no treatment– Options for Tooth Replacement– Option of going to a Specialist

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Informed Refusal

• When a patient refuses a treatment you feel is necessary, and failure to have the procedure may result in life - or health-threatening consequences, the patients should sign a form stating that they have been informed of all of the consequences of their decision.

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Antibiotic Premedication

• Indications Cardiac Valvular lesions that may predispose toward endocarditis

1. Prosthetic heart valve2. Most congenital heart

malformations3. Rheumatic valve disease4. Degenerative valve disease5. Idiopathic hypertrophic subaortic

stenosis6. Mitral valve prolapse with

insufficiency7. Previous episode of bacterial

endocarditis

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Antibiotic Premedication

• Indications ØCoronary artery stentsØCABGØPacemakersUsually 1st 6 months

after placement-once epithelialized

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Antibiotic Premedication

• Indications ØProsthetic JointsUsually 2 years after

placement

ØHematogenous Joint InfectionØ Inflammatory

arthropathyØ ImmunosuppressionØ IDDMØHemophiliaØPrevious joint infection

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Antibiotic Premedication

• Indications• ControversiesØImplants

• Breast• Dental

–Yes• Deep tissue• Poor blood supply• Difficult to treat

implant infection

–No• Superficial implant• Good blood supply• Easily treated

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Antibiotic Premedication

• Indications• Controversies• Standard

Regimen

ØAmoxicillin 2.0 gØClindamycin 600 mgØCephalexin 2.0 gØAzithromycin 500 mg1 hour before procedure

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Antibiotic Premedication

• Indications• Controversies• Standard

Regimen• IV Regimen

ØCephazolin 1.0 g IVØClindaymycin 600mgWithin 30 minutes

before procedure

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Prophylaxis for Dental Procedures

YES• Tooth extraction• Periodontal surgery• Subgingival dental

prophylaxis• Endodontic surgery• Incision and drainage of

infections

NO• Supragingival prophylaxis• Restorative dental work• Placement of orthodontic

appliances• Suture removal• Nonsurgical endodontic

therapy• Impression taking• Radiographs

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Prophylactic Antibiotics

• If there is infection present, antibiotic therapy should be directed against likely pathogen.

• If patient is taking antibiotic normally used for SBE prophylaxis, premed with drug from different class.

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“Routine Antibiotics”

• Antibiotics should not be prescribed without a clinical indication. – Infection spread to soft tissues at surgery– Prolonged procedure, excessive bone removal– Adequate blood levels

• 3 – 4% overall infection rate after third molar extraction.

• Antibiotics do not significantly reduce the risk of postoperative infection in an otherwise “clean”case.

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“Routine Antibiotics”

• Antibiotics are over-prescribed for routine oral surgery.

• Risks of over-use:–Allergic reactions–Resistance

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Surgical Management

Bleeding from surgical sites can usually be controlled by

local measures

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Local Measures to Control Bleeding

• Gauze pressure• Pack site- gelatin sponge

(Gelfoam), absorbable oxycellulose (Surgicel)

• Suturing• Topical thrombin• Local anesthetic

• Bone wax• Cyanoacrylate tissue

glue (Dermabond, Histacryl)

• Rinse with amino-caproic acid or tranexamic acid (5%)Ø Hold in mouth for 2.5

min pre-op, then q2h for 6-10 doses

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Post-Operative Instructions

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Management of Common Postoperative Complications

• Infection• Sinusitis• “Dry socket”• Sequestration• Lingual mandibular sequestration • Fracture• Numbness

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Postop Infection

• Occurs after 3r d postop day• Increased swelling, pain• Foul or sour taste• Fever

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Postop Infection

• Treat initially with “standard”antibiotics

• May require debridement of extraction socket

• Place drain if involves soft tissues

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Sinus Problems

• The maxillary posterior teeth may project into the maxillary sinus

• Sinusitis: – Amoxicillin 500mg TID x 14 days– Decongestant

• Oral-Antral Fistula– Will probably close by itself– If not closed by 2 weeksà Refer

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Dry Socket• Localized Alveolar Osteitis• Loss of the blood clot• Etiology??• “Schmootzy” socket• “Reznick’s sign”

(chandelier sign)• Treatment• Prevention

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Dry Socket

A true dry socket should not last more than a few days. If it does, look

for another cause of the patient’s symptoms.

““When things donWhen things don’’t seem right, t seem right, therethere’’s a good chance that s a good chance that

somethingsomething’’s wrongs wrong””

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Bony Sequestration

• Small pieces of bone may become obvious at the extraction up to many months after surgery

• Most will slough without treatment• Can be removed with small rongeur

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Post-Surgical Complications

• Lingual bony spicule– Can develop anytime after surgery

for mandibular 3rd molars, even years later.

– Painful, radiates to ear, throat, headache

– Can occur spontaneously.– Bony spicule is visible along

mylohyoid ridge, penetrating lingual mucosa.

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Lingual Bony Spicule

• May be self-limited– Exposed bone

becomes necrotic– May slough, leaving a

smooth surface underneath

– Mucosa will heal spontaneously

• May need intervention

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Lingual Bony Spicule

• Make incision about 2-3mm above spicule

• Elevate flap with curved Molt currette

• Smooth/ remove spicule with angled bone file (H&H)

• Suture closed with 4-0 chromic gut

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Mandible Fracture

• Most frequent when:– Patient is a male, > 35 years old– Deep impaction– Infection present before surgery– Impaired healing potential

• Usually occurs 1-3 weeks after surgery• Refer immediately• Treatment: Closed vs. Open Reduction

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Post-Op Paresthesia

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Surgical Nerve Injury• IncidenceØ0.5%: TransientØ1/20,000 – 1/25,000: Permanent

• PrognosisØParesthesia vs. Anesthesia

• MedicationsØCorticosteroidsØNeurontin

• Surgery?ØObserved transectionØTotal anesthesiaØDysesthesia

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Factors Affecting PostOpRecovery

• Amount of flap reflection

• Surgical time• Instrumentation• Irrigation• Corticosteroids• Pre-operative

symptoms

• Surgeon experience• Patient age• Bone density• Root development• Tooth position• Individual variation

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Odontogenic Infections

• Perio/Endo Infections

• Pericoronitis

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Dental Infections

• A tooth should not be removed in the face of active infection.

• You must put the patient on antibiotics first, then take out the tooth when the infection is better.

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Odontogenic Infections• Perio/Endo Infections

1) Remove the source of the infection

2) I & D3) Antibiotics

• Pericoronitis1) Usually cellulitis2) Begin treatment for soft

tissue infection before removing tooth

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Antibiotic Use

• Indicated for:– Acute onset

infection– Diffuse swelling– Compromised host

defenses– Involvement of

fascial spaces– Severe pericoronitis– Osteomyelitis

• Not Indicated for:– Chronic well -

localized abscess– Minor vestibular

abscess– Dry socket– Mild pericoronitis

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Antibiotic Use

Most odontogenic infections respond readily to the “standard” antibiotics

•Penicillin•Amoxicillin•Erythromycin•Clindamycin

•Cephalexin•Ceclor•Metronidazole•Tetracycline

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Reasons for treatment failure

– Inadequate surgery– Depressed host defenses– Foreign body– Antibiotic problems

• Patient noncompliance• Drug not reaching site• Drug dosage too low• Wrong bacterial diagnosis• Wrong antibiotic

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Indications for C & S:– Rapidly spreading

infection– Postoperative

infection– Nonresponsive

infection– Recurrent infection

– Compromised host defenses

– Osteomyelitis– Suspected

actinomycosis

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Incision & Drainage (I&D)

• Fluctuant vs. Indurated– Pus– Cellulitis

• Letting out the pus– Incision and Drainage

• Draining cellulitis

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Criteria for referral to a specialist

• Rapidly progressing infection

• Difficulty in breathing

• Difficulty in swallowing

• Fascial space involvement

• Elevated temperature (> 101° F)

• Severe jaw trismus(< 20 mm)

• Toxic appearance• Compromised host

defenses

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Pathology in a Nutshell(as learned in Dermatology)

• If it is Raised:– Cut it off– Biopsy

• If it is Flat:– Try topical

steroids– If it doesn’t go

away• Cut it off• Biopsy

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Biopsy

• Incisional:– Large lesion– Generalized condition– Possibly malignant– Diagnosis not definitive

• Excisional– Small lesion– Most likely benign– Can be completely

excised– Will not require further

treatment

Incisional vs. Excisional

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Biopsy Guidelines• Excise down to

connective tissue layer• If ulcerative, biopsy

near edge• If suspect malignancy,

biopsy “worst” area• If excising, excise

completely, consider closure

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Laser Biopsy

• Great technique!• Don’t cook specimen• Laser is not a magic

wand- it does not replace the scalpel-use appropriately!– Raised– Benign– Excisional biopsy

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Pitfalls- Procedural

• “I’ve got time on my schedule”• “It looks easy”• Not having the correct instruments• Not laying a flap/ big enough flap• Not planning/ being prepared• Not referring the patient to the OS to begin

with! – Offer patient options: GP or OS

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Help!

• Develop a working relationship with a local Oral and Maxillofacial Surgeon

• You need him/her• He/She needs you!

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Pitfalls- MedicoLegal

• Inadequate informed consent• Inadequate radiographs• Poor records• Failure to call for help/ refer to specialist• Failure to inform patient of complication• Ignoring a patient’s complaint of a

complication• Failure to give patient option of seeing a

specialist

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References- Basic

MosbyJBR

References

W B Saunders

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www.scofsg.com/pt_forms.htm