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Flashcards in Oral Surgery Deck (312):
1

Trigeminal nerve (CN V)

largest CN, the principal general sensory nerve to the head and face, sensory and motor

motor root exits foramen ovale

2

does CN V have parasympathetics at its origin?

NO

3

mandibular division of CN V innervates how many muscles?

8

4

CN V somatic SENSORY bodies of the ganglion's sensory fibers enter the 3 divisions:

V1 Ophthlamic - ORBIT and SKIN above eyes

V2 Maxillary - nasal cavity, max teeth, palate, skin over maxilla

V3 Mandibular - mandible, TMJ, mand teeth, FOM, tongue, skin of mandible

5

CN V, axons of neurons enter the __ through the sensory root and terminate in 1 of 3 nuclei of the trigem sensory nuclear complex (3)

PONS

1. mesencephalic - proprioception ex. muscle spindle
2. main sensory - general sensation ex. touch
3. spinal nucleus - pain and temp

6

proprioceptive fibers from muscles and TMJ found in which CN V division?

cell bodies of proprioceptive 1st order neurons are found in the __ nucleus

V3

mesencephalic NOT the trigem ganglion

7

branchiomeric motor fibers innervate which muscles?

Temporalis
Masseter
Medial and Lateral Pterygoids
Anterior belly of the Digastric
Mylohyoid
Tensor tympani
Tensor veli palatini

8

Mandibular Div (V3) of the trigem passes through __ and supplies sensory/motor? innervation to these muscles

foramen ovale
MOTOR

to tensor veli palatini, tensor tympani, muscles of mastication (temporalis, masster, lateral and medial pterygoids), anterior belly of digastric, mylohyoid muscles

9

CN V3 sensory innervation (4 nerves)

1. long buccal (sensory only) -> cheek, md buccal gingiva

2. auriculotemporal (sensory only) -> TMJ, auricle, external auditory meatus

3. lingual (sensory only) -> FOM, mand lingual gingiva, anterior 2/3 tongue

4. inferior alveolar nerve (sensory & motor!) -> mand teeth, chin skin, lower lip

10

massteric nerve is a branch of CN V3 that carries sensory/motor? fibers to the TMJ's anterior portion

sensory

11

auriculotemporal nerve is a branch of VN V3 that provides major sensory/motor? innervation to the TMJ's posterior portion

also transmits pain in the TMJ __ and __

SENSORY

pain in TMJ capsule and disc periphery

12

nerve to mylohyoid muscle is a branch of the mandibular nerve (V3), functions to?

elevate hyoid bone, base of tongue, FOM
-sublingual gland is superior to mylohyoid muscle

13

when the floor of the mouth is lowered surgically, the __ and __ muscles are detached

mylohyoid & genioglossus

14

suprahyoid muscles (4) and their innervations

1. Digastrics (ant and post) - CN V3 (ant), CN VII (post)
2. Mylohyoid - CN V3
3. Geniohyoid - C1 via hypoglossal CN XII
4. Stylohyoid - CN VII

15

infrahyoid muscles (4) and their innervations

1. Thyrohyoid
2. Omohyoid
3. Sternohyoid
4. Sternothyroid

all innervated by Ansa Cervicalis (loop formed by branches of cervical plexus C1, C2, C3)

16

hypoglossal nerve is a motor nerve supplying what muscles?

all intrinsic and extrinsic tongue muscles EXCEPT palatoglossus (vagus nerve)

17

unilateral lesions of the hypoglossal nerve cause deviation of the protruded tongue to the affected or opposite side?

affected side, cause of lack of fxn of genioglossus on diseased side

18

if the __ muscle is paralyzed, the tongue can fall back and obstruct the oropharyngeal airway

genioglossus

19

carotid sheath location? what does it contain?

lateral boundary of retropharyngeal space at level of oropharynx, deep to SCM muscle

contains carotid arteries, internal jugular vein, vagus nerve, deep cervical lymph nodes

20

when you retract the carotid sheath, the __ __ __ stays because it is not within the sheath

cervical sympathetic trunk

21

facial vein unites with the __ vein below the border of the mandible and empties into the internal jugular vein

retromandibular

22

internal jugular vein descends through neck inside carotid sheath, eventually to forms the

superior vena cava -> right atrium

23

max 1st molar innervated by what nerves

middle superior and posteiror superior alveolar

24

what injection must you give to ext all molars and 2nd PM?

long buccal

25

greater (anterior) palatine nerve is a branch of the maxillary (CN V2) that innervates?

GP foramen is where?

soft tissue to posterior 2/3 of hard palate -> canine (overlaps with nasopalatine)

btw 2nd and 3rd max molar, ~1 cm from palatal gingival marign toward midline

26

which cranial nerves have parasympathetic activity?

III
VII
IX
X

27

Cranial nerves (12)

I - olfactory - smell
II - optic - sight
III - oculomotor - eyeball movement, pupils, vision
IV - trochlear - eyeball movement
V - trigem - sensation to face, scalp, teeth, muscles of mastication, mandible movement
VI - abducens - eyeball movement
VII - facial - taste, face muscles, saliva secretion
VIII - vestibulocochlear - hearing, equilibrium
IX - glossopharyngeal - taste, sensory for cardiac, respiratory, bp reflexes, pharynx contraction, saliva
X - vagus - sensory in cardiac, respiratory, bp reflex, larynx, decr HR, peristalsis, incr. digestive secretions
XI - accessory - contract neck and shoulder
XII - hypoglossal - motor to tongue except palatoglossus

28

external carotid artery supplies?

passes through the __ gland

most of head and neck cept brain

through parotid salivary gland

terminates as max and superficial temporal arteries

29

maxillary artery supplies what?

3 branches

max and mand teeth, muscles of mastication, palate, nasal cavity

IA artery -> mand teeth
PSA artery -> post max teeth
ASA & MSA -> ant max teeth

30

venous return of both dental arches is?

pterygoid plexus of veins

31

greater (descending) palatine artery supplies?

hard palate, gingiva of max teeth and lateral nasal wall

lesser palatine also does tonsils

32

lingual artery supplies?

arises from? terminates as?

blood to tongue (also gets blood from tonsillar branch of facial artery and ascending pharyngeal artery)

also supplies FOM

arises from external carotid artery, terminates as deep lingual artery

does NOT accompany its nerve throughout its course

33

lingual artery branches (4)

suprahyoid
dorsal lingual
deep lingual - anterior 2/3 tongue
sublingual

34

inferior alveolar nerve and artery, and lingual nerve are found in the __ space?

PTERYGOMANDIBULAR SPACE btw medial pterygoid and ramus of mandible

IA nerve passes lateral to sphenomandibular ligament

35

tongue sensory innervation

lingual nerve (branch of V3) - ant 2/3 tongue

glossopharyngeal (CN IX) - post 1/3, vallate papillae, tonsil, nasopharynx, pharynx

vagus (CN X) via internal laryngeal nerve - near epiglottis

facial nerve (CN VII) via chorda tympani - taste to ant 2/3

36

facial nerve CN VII exits cranium through __ and extends laterally around mandible thorugh the __ gland

stylmastoid foramen

parotid gland

37

fxns of facial nerve

1. motor - muscles of expression, post belly digastric, stylohyoid, stapedius
2. sensory (proprioception) - muscles of facial expression
3. motor (parasympathetic) - tear secretion from lacrimal gland, salivary from sublingual and submand glands
4. sensory (taste and sweet) - taste buds ant 2/3 tongue, FOM, palate

38

Parotid gland is a pure __ gland supplied by general visceral efferent (motor) nerve fibers of the __ nerve.

Drained by?

supplied by what artery?

lymphatic drainage?

SEROUS, glossopharyngeal nerve

Stenson's duct - pierces buccinator, crosses masster where it opens opposite max 2nd molar

external carotid artery

lymph -> parotid nodes to deep cervical lymph nodes

39

the only other adult salivary glands purely serous

Von Ebner's
-around circumvallate papilla of tongue
-fxn to rinse food away from papilla

40

__ is a viral disease of the parotid gland

mumps

41

Wharton's duct (submandibular) is closely related to what nerve?

innervated by?

blood supply from?

LINGUAL NERVE

parasympathetic secretomotor fibers from FACIAL NERVE

FACIAL ARTERY

42

sublingual gland is the smallest salivary gland that contains mostly ___ acini

MUCOUS
-in FOM below tongue, close to midline
-has many small RIVIAN ducts
-secretory units are mucous secreting with serous demilumes

43

lymphatic drainage from the sublingual and submandibular glands goes to what lymph nodes

submandibular, deep cervical

44

sometimes the numerous sublingual ducts join to make a main excretory duct called __ that empties into the __ duct

Bartholin's Duct -> submandibular

45

in the H&N, all lymph ultimately rains into the __ lymph nodes

deep cervical
-form a chain along course of the internal jugular vein
-efferent lymph vessels join to form jugular lymph trunk, drains into thoracic duct or right lymphatic duct

46

regional lymph nodes (3)

1. parotid
2. submandibular - max and mand teeth, ant 2/3 tongue, paranasal sinuses
3. submental - mand incisors and gingiva, tip tongue, FOM, center lip

47

maxillary sinuses open into

innervation?

hiatus semilunaris

max division of trigem nerve (CN V2 - incl ASA, PSA, MSA, infraorbital)

48

antibiotics to treat sinus infxns

ampicillin - sinusitis from upper respiratory infxns

penicillin and amoxicillin - sinusitis caused by odontogenic foci

49

max sinus communication

if tooth or large fragment displaced, what do you do?

if small then just allow blood clot

if fragment then remove it, if you can't get it thru socket then use Caldwell-Luc approach

50

integrity of max sinus floor is at greater risk with surgery removing a single remaining max molar cause of

possible ankylosis

51

pterygopalatine fossa is a small space where?

what nerve and artery passes through?

behind and below orbital cavity

max nerve (V2) and artery

52

buccinator originates from 3 areas:

what arteries supply it?

action?

pterygomandibular raphe (btw buccinator and superior constrictor), maxillary and mandibular alveolar processes

facial and maxillary arteries

action - compress cheeks against molars for sucking and blowing

53

these muscles are the primary protractors of the mandible

lateral pterygoids
-open and protrude, mandible side to side

ex. right lateral movement, the LEFT is the mover

54

mandible deviates toward/away site of injury in condylar ankylosis, unilateral condylar fracture, latearl pterygoid injury

TOWARD

55

mandible deviates toward/away site of injury in cases of condylar hyperplasia

AWAY

56

what muscle forms the roof of the pterygomandibular space?

lateral pterygoid

57

masticator space is composed of what 3 spaces?

infxns are almost always of dental origin from what region?

symptoms?

masseteric, pterygomandibular, temporal

mandibular molar region

TRISMUS, pain, swelling

58

needle tract infxn after IA block initially involve what space?

pterygomandibular

59

most definite clinical sign indicating extension of odontogenic infxn into masticator space

TRISMUS
-can also be caused by passing needle through medial pterygoid muscle during IA block

60

temperomandibular joint is the articulation btw mandibular condyle and squamous portion of what bone?

temporal

61

TMJ components (4)

1. mandibular condyle (condyloid process)
2. articular fossa (mandibular or glenoid)
3. articular eminence (articular tubercule)
4. articular disc (meniscus)

62

condyle surface is covered with

vascular layer of fibrous CT

63

articular fossa (mandib or glenoid)

concave fossa, anterior 3/4 of larger mandib fossa

NON-FUNCTIONING

64

articular eminence (articular tubercule) is a

CONVEX ridge lined with fibrous CT (fibrocartilage)

FUNCTIONAL and articular portion of the TMJ

65

articular disc is

bioconcave, saddle shaped, made of fibrous CT
-central intermediate zone separates anterior and posterior bands
-posterior band has RETRODISCAL tissue/bilaminar zone which is VASCULAR and INNERVATED
-anterior band is thinner, contiguous with capsular, condyle, superior belly of lateral pterygoid

66

muscles acting on TMJ

masseter, temporalis, pterygoids, digastric

67

3 TMJ ligaments are

1. Temperomandibular (lateral)
2. Stylomandibular
3. Sphenomandibular

68

Temperomandibular ligament

fxn?

major one from articular eminence to condyle, the ONLY one that directl ysupports TMJ capsule

-prevents posterior and inferior displacement of condyle

69

Stylomandibular ligament

accessory ligament, separates infratemporal from parotid region, located on POSTERIOR border of mandible

70

Sphenomandibular ligament

accessory ligament, located on MEDIAL surface of mandible

71

4 arteries that vascularize TMJ

1. Middle meningeal (branch of maxillary, terminal branch of external carotid)
2. Ascending pharyngeal
3. Deep auricular
4. Superficial temporal (terminal branch of external carotid)

72

TMJ syndrome divided in 3 categories

1. Myofascial pain
2. Internal derangement (disc displacement)
3. Degenerative join disease (osteoarthritis)

73

what's the syndrome that's the most common cause of TMJ pain?

myofascial pain dysfunction (MPD)
-involves muscles of mastication
-STRESS related
-responds to night guard

74

internal derangement (disc displacement) is

most common direction for disc to be displaced?

abnormal relationship of articular disc to condyle, fossa and articular eminence

anteriorly - retrodiscal tissue (bilaminar zone) becomes abnormally stretched

75

if posterior band returns to normal position then this condition is called

anterior displacement with reduction
"pop" or "click"

76

subluxation (dislocation or open lock) is when

pt can't close mouth

77

disc displacement WITH redxn is when

signs?

disc is out of place, hear a "click", painless

patient has normal opening or "S" shaped, TMJ is only ROTATING (not translating), reciprocal clicking on opening and closing
-on closing, the disc is forward to condyle

78

disc displacement WITHOUT reduction (closed lock) is when

jaw deviates toward/opposite affected side?

what direction are disc displacements?

clicking and opping is gone with limited opening and pain, a HARD-END feel

deviates TO affected side

NO reciprocal click

most displacements -> ANTERIOR and MEDIAL

79

most common cause of restricted mandibular movement is

disc interference disorders

80

best way to palpate posterior aspect of the condyle is?

EXTERNALLY over posterior surface of condyle with mouth open
-palpate laterally in front of external auditory meatus while pt opens and closes

81

what is the best incision to expose the TMJ?

preauricular

anterior to external ear, parallel to superficial temporal artery, be careful of facial nerve

82

__ approach is the standard to approach the mandibular ramus and neck of the condyle

Submandibular (Risdom)

83

the most common cause of TMJ ankylosis

TRAUMA

84

most common complication of rheumatoid arthritis

ankylosis

85

control of __ is vital to tx any pt with a facial fracture

airway

86

highest incidence of fractures occurs in what population

young males 15-24, trauma

87

3 muscle groups displace the condyles

1. masseter, medial pterygoid, temporalis
-ELEVATE mandible during mastication, causes UPward displacement of proximal segment

2. digastric, mylohyoid, geniohyoid, lateral pterygoid
-DEPRESS mandible and displaces DISTAL segment inferiorly and posteriorly

3. lateral pterygoid
-FORWARD displacement of condylar head when the condylar neck is fractured

88

30% of fractures in the mandible happen in the
25% in the
22% in the
17% in the

1. ANGLE - proximal segment usually displaced anteriorly and superiorly
2. condylar neck
3. symphysis (chin)
4. body of mandible
5. ramus (2%)
6. coronoid process (1%)

89

on opening, pt's mandible deviates toward/opposite injury?

TOWARD

90

most common pathognomonic sign of mandibular fracture is

MALOCCLUSION

91

open reduction is?

most common site is?

indications?

the reduction of a fractured bone by manipulation after incision into skin and muscle over fracture site

mostly at ANGLE of mandible

best when teeth are missing in one or more of the fractured segments, when there's continued gross displacement of the segments

92

condylar neck fractures best treated by what method?

CLOSED reduction

93

closed reduction is?

intermaxillary fixation is?

rdxn of fractured bone by manipulation without incision into skin

applying wires or elastics btw jaws, most common is PRE-FAB arch bars

94

bilateral sagittal split osteotomy most common to correct?

mandibular retrognathia (Class II malocclusion)

split mandible can be advanced or set back

*position of condyle is UNCHANGED

95

vertical ramus osteotomy is used to correct

mandibular PROgnathism

96

body osteotomy is used to correct

mandibular PROgnathism (Class III malocclusion)
-ext mand teeth bilaterally (usually PMs)

97

ways to immobilize a fracture (4)

1. Barton bandage
2. Intermaxillary fixation (IMF)
3. external skeletal fixation
4. Direct intraosseous wiring + IMF, traditional method after OPEN RDXN

98

greenstick fracture

mand fracture that extends only thru cortical portion of bone without complete fracture; most common in KIDS

99

classifications of mandibular fractures (3)

1. simple - 2 parts with no external communication (closed)

2. compound - communicates with outside (open), most common complication is INFECTION

3. comminuted - multiple fractures of a single bone that can be either single or compound

100

unfavorable fracture occurs if fracture line results in ___

favorable fracture occurs if fracture line __

muscle pull displacing the fracture segment

prevents displacement of fracture by muscle pull

101

midfacial fractures affect these 3 structures

maxilla
zygoma
nasoorbital ethmoid complex

102

6 types of midfacial fractures
1. LeFort I
2. LeFort II
3. LeFort III
4. Zygomatic complex
5. Zygomatic arch
6. Nasoorbital Ethmoid

1. LeFort I - HORIZONTAL, causes OPEN BITE, used to correct Mx RETROgnathia
2. LeFort II - PYRAMIDAL, PARESTHESIA common over infraorbital nerve
3. LeFort III - TRANSVERSE or CRANIOFACIAL dysfunction, restricted mandibular movement
4. Zyogmatic complex - most common, can have paresthesia, hematoma in sinus, impaired ocular muscle
5. Zygomatic arch - no probs
6. Nasoorbital Ethmoid

103

what are the 1st and 2nd most common fractures of facial bones?

1. nasal
2. zygomatic bone

104

signs and symptoms of zygomatic fracture

binocular diplopia, trismus, ipsilateral epistaxis

105

what view is best to evaluate orbital rim areas?

Water's view

106

symptoms of fracture of infraorbital rim?

numb upper lip, cheek, nose on affected side

107

3 radiographic views for midfacial fractures

1. Water's
2. PA skull
3. submental vertex

108

blows to the maxilla drive the maxilla in what direction? results in what kind of bite?

back and down -> open bite or impinged airway

109

segmental osteotomy is?

maxilla sectioned into 2+ pieces

110

fracture healing (4)

1. Endosteal proliferaiton - in bone
2. Periosteal proliferation - in CT
3. Primary (bone to bone) healing - endosteal and periosteal proliferation
4. Secondary bone healing - mostly endosteal proliferation

111

3 phases for healing bone

1. hemorrhage - first 10 days
2. callus formation - in 10-20 days, then a secondary callus
3. functional reconstruction - line up Haversion systems, bold will be molded, takes 2-3 years

112

4 reasons fractures don't heal

1. ischemia
2. excess mobility
3. interposition of soft tissue
4. infection

113

___ is the most of often sequela of fractures

FAT embolism

114

3 types of inappropriate healing

1. delayed-union: satisfactory healing
2. non-union: failure of segments to unite properly
3. mal-union: can be delayed or complete union in an improper position

115

Geudel's stages of general anesthesia (4)

1- Amnesia & Analgesia - best monitor is VERBAL

2- Delirium/Disinhibition & Excitement - loss of consciousness, onset of total anesthesia

3- Surgical Anesthesia - regular pattern of breathing, total loss of consciousness, 4 planes, spinal reflexes depressed, no pain reflexes

4- Premortem or Medullary Depression - signals danger, dilated pupils, cold skin, low bp, cardiac arrest imminent, severe respiratory and cardiovascular depression

116

3 agents for surgical anesthesia

cyclopropane - good muscle relaxant

halothane - not good muscle relaxant, not good analgesic, halogenated hydrocarbons are assoc. with liver damage if toxic doses are used

methoxyflurane - good muscle relaxant, respiratory depressant, good analgesic

117

ASA classes (6)

I - healthy
II - mild systemic disease
III - severe disease not incapacitating
IV - severe systemic disease, threat to life
V - moribound pt not expected to survive without operation
VI - brain dead

118

elements of general anesthesia include (4)

analgesia
relaxation
hyporeflexia
narcosis

119

__ is the last area of the brain depressed during general anesthesia

medulla
-contains cardiac, vasomotor, respiratory centers of the brain

120

most reliable sign of "oxygen want" is

increased pulse rate
cyanosis may also be present

121

most common emergency during outpatient general anesthesia is

respiratory obstruction

122

best anesthetic technique used in OS to avoid aspiration of blood or other debris when a pt is under general is

endotracheal intubation with pharyngeal packs

123

pt with __ infxn is contraindicated in general anesthesai

acute respiratory

124

Induction is

starts with admin of anesthetic and continues until desired level of pt unresponsiveness is reached

rate and recovery depends on rate of change of tension in tissue, blood supply to lungs, pulmonary ventilation, concentration of anesthetic influence

125

Recovery is

when surgery is complete and delivery of anesthetic is terminated; ends when anesthetic is eliminated in the body

126

dissociative anesthesia

reduces anxiety and produces a trance-like state where the person is not asleep but feels separated from their body, good for KIDS, they usually don't remember, can have intense dreams or hallucinations

127

__ is the primary med used in dissociative anesthesia

KETAMINE, but usually give them a sedative first to reduce anxiety

128

local anesthetics are most effective in tissue about pH __ cause __

7 (alkaline)
locals are alkaloid bases combined with acids to make water-soluble salts

129

local anesthetics affect the nerve membrane by INCR/DECR? membrane's permeability to Na+ and INCR/DECR membrane's excitability

DECR membrane permeability
DECR membrane's excitability

bind to inactivation gates of fast voltage gated Na channels

K, Ca, Cl conductances are unchanged

reversibly block nerve impulse conduction and produce reversible loss of sensation

130

which nerve fibers are affected first by local? and last?

small NONmyelinated nerve fibers (pain, temp) > touch > proprioception > skeletal muscle tone

131

max. allowable dose of 2% lido with 1:100000 epi?

carbo with no epi?

max dose of epi for cardiac-risk pt?

3.2 mg/lb or 7 mg/kg

3.0 mg/lb

0.04 mg (if 1:50000 then 1 carp, if 1:100000 then 2 carps, if 1:200000 then 4 carps)

there is 0.018 mg epi in each carp of 2% lido with 1:100000 epi

132

1 cc 2% lido with 1:100000 epi has how much

mg lido?
mg epi?
mg NaCl?
mg sodium-metabisulfate?
mg methylparaben?

20 mg lido
0.01 mg epi
6 mg NaCl
0.5 mg sodium-metabisulfate (preservative to stabilize epi)
1 mg methylparaben

133

allergic rxns are more common in esters or amides?

esters

usually caused by an antigen-antibody rxn

134

PABA esters include

procaine (novocain)* was the prototype
tetracaine/pontocaine (most common)
propoxycaine (ravocaine)
benzocaine (monocaine)
cocaine

135

ester local anesthetics undergo rapid biotransformation in __

amides undergo biotransformation where?

blood plasma
hydrolysis to PABA by the enzyme pseudocholinesterase (can't detox ester agents at a normal rate so use amides instead)

amides in LIVER by microsomal enzymes

136

amide local anesthetics include

prilocaine (citanest)
bupivicaine (marcaine)
LIDOCAINE/XYLOCAINE (most common)
mepivacaine (carbocaine)
etidocaine (duranest)

137

what do you use for pts allergic to esters and amides?

diphenhydramine

138

local anesthesia works by?

reducing anxiety and sensitivity during the procedure

139

__ is the local anesthetic that may manifest toxicity clinically by initial depression and drowsiness

lidocaine
-usually it's stimulation first

140

what 2 anesthetics can show cross-allergenicity?

lido and mepivacaine

141

first clinical sign of mild lidocaine toxicity is?

nervousness

related to CNS excitation

142

how do you tx sustained convulsive rxns to locals?

oxygen
diazepam IV

143

side effects of lido systemic absorption

tonic-clonic convulsions
respiratory depression
decreased CO

144

4 reasons why vasoconstrictors (ex. epi) are placed in locals

1. prolong duration of action*
2. reduce toxicity
3. reduce rate of vascular absorption by causing vasoconstriction
4. more profound anesthesia by incr. concentrations at nerve membrane

145

do vasoconstrictors reduce the change of developing an allergic rxn?

NO

146

3 anesthetics that contain epi

lido
prilo
marcaine

147

what anesthetic contains levonordefrin (neo-cobefrin)?

which one has norepi?

mepivacaine

procaine

148

vasoconstrictors act at what receptors to constrict arterioles?

cocaine is an instrinsic vasoconstrictor that does what?

alpha receptors

increases PRESSOR activity of both epi & NE

149

local anesthetics depress small/big? myelinated or non? nerve fibers FIRST and what last?

small non-melinated first
then large, myelinated fibers last

variations depend on nerve diameter and distance btw nodes of Ranvier

150

clinically, order of loss of nerve fxn from a local anesthetic is (5)

pain - temperature - touch and pressure - proprioception - skeletal muscle tone

151

what is the drug of choice for managing an acute allergic rxn involving bronchospasm and hypotension?

epi

152

inhalation anesthetic with fastest onset

it inhibits what enzyme that is required for vit B12 production?

nitrous oxide
-poorly soluble in blood
-in surgery provides light anesthesia

inhibits methionine synthetase

153

cons of N2O

inhalation of 100% oxygen is contraindicated in a pt with what condition?

nausea, diffusion hypoxia

COPD

154

N20 contraindications

hypoxemia, respiratory disease, emotional instability, contagious diseases

OK for pregnant pt

155

N20 works where? organic or inorganic?
excreted where?

main effect on what systems?

first symptom is?

CNS, INORGANIC, excreted by lungs (unchanged)

reticular activating and limbic systems

tingling of hands

156

neurolept analgesia only produces an unconscious state if __ is also administered

nitrous oxide

157

neuroleptic (droperidol) + narcotic analgesic (fentanyl) is

neurolept ANALGESIA (conscious)

158

neuroleptic + narcotic analgesic + N2O is

neurolept ANESTHESIA

159

nitrous oxide and ethylene are useful only for __ and __

sedation and analgesia

N2O: ventricular fibrillation is LEAST LIKELY to occur with nitrous

ethylene: rapid induction and recovery, but explosive and stinks

160

primary danger with using N2O > 80% conc. is

hypoxia

161

desflurane is

inhalation anesthetic, but irritates airway

162

SPEED of inhalation induction of anesthetics depend on 5 things

1. gas solubility* (more soluble, slower rate of induction)
2. inspired gas partial pressure
3. ventilation rate
4. pulmonary blood flow
5. arteriovenous conc. gradient

163

admin of inhalation anesthetic is usually preceded by administration of what drug

IV or intramuscular admin of a short-acting sedative hypnotic (often a BARBITURATE)

164

barbiturates do what to the CNS?

2 major effects?

drugs to avoid in pts taking barbiturates?

last tissue to become saturated?

properties?

DEPRESS the CNS

effects - sedative, hypnotic

avoid - phenothiazines, alcohol, antihistamines, antihypertensives

FAT is the last to be saturated cause it's not as vascular

properties - respiratory depression, induction of liver microsomal enzymes, tolerance development, suppression of REM sleep, hyperanalgesia (incr sensitivity to pain)

165

most effective agent in initial tx of respiratory depression from overdose of barbiturates is

oxygen under positive pressure

166

most resistant part of CNS under general anesthesia is the

MEDULLA OBLONGATA

167

most controllable route of admin of general anesthetic is

inhalation

168

most common drug used to attain general anesthesia is

most common side effect?

brevital (methohexital)
-an IV barbiturate, induce anesthesia in short surgery as supplement to other aneshetics

side effect - hiccoughs

169

malignant hyperthermia is what kind of condition?

characterized by?

autosomal dominant inherited condition, life threatening, acute pharmacogenetic disorder in pts undergoing general anesthesia

sudden rapid rise in body temp, incr. muscle metabolism (tachycardia, tachypnea, sweating, cyanosis, incr CO2 production, muscle rigidity)

170

the only drug that treats malignant hyperthermia

dantrolene

171

optimum site for IV sedation is what vein?

avoid entering what artery?

median cephalic vein
avoid brachial artery

172

IV sedation usually with what drug?

3 common signs that indicate correct level of sedation has been reached?

Valium (diazepam)

signs - blurred vision, slurring of speech, 50% ptosis of eyelids (Verrill's sign)

173

phlebitis (thrombophlebitis) of a vein after admin of IV valium is usually due to __ in the mixture

clinical observations of phlebitis? (4)

propylene glycol

obs - vessels are hard, sensitive to pressure, area is erythematous and warm, limb is pale/cold/swollen

174

scopolamine is a drug structurally similar to
__

good for preventing __

acetylcholine

good for motion sickness
-depresses CNS, a sedative and anti-spasmodic
-rdxn of secretions by competitive block of ach and other cholinergic stimuli

175

anticholinergic drugs work by:

interfering with binding of Ach at its receptor
-categorized by ionization state of nitrogen (affects ability to penetrate CNS)
-it's an anti-sialogue (decreases saliva!)

176

tertiary anticholinergic compounds include?

atropine, benztropine, scopolamine

-atropine is contraindicated for nursing mothers and pts with glaucoma (atropine causes MYDRIASIS, dilated pupils)

-these decr saliva flow and secretion from respiratory glands

177

quaternary anticholinergic compounds include?

glycopyrrolate, ipratropium, probanthine - can't penetrate CNS

178

Air volumes

1. TV
2. RV
3. ERV
4. IRV
5. VC
6. FRC

1. tidal - air inhaled
2. residual - what doesn't participate in ventilation
3. expiratory reserve - what can be exhaled in addition to TV
4. inspiratory reserve - what can be inhaled in addition
5. vital capacity - total lung capacity
6. functional reserve capacity - air left in lungs at end of expiration

179

pulmonary volumes and capacity or __ % less in females than males

20-25

180

laryngospasm is a

how do you manage?

acute spasm of vocal cords and epiglottis

manage by applying oxygen under positive pressure and aministering succinylcholine

181

universal sign of laryngeal obstruction is?

what do you administer?

STRIDOR (crowing sounds)

give epi and oxygen

182

if oxgen doesn't get to lungs, blood, brain, permanent neurologic damage occurs in how many minutes?

3-5

183

tracheotomy is for

cricothyrotomy for

long-term airway maintenance

EMERGENCY airway, ex. anaphylactic rxn

184

in an IA block, needle passes through mucous membrane and what muscle? and lies lateral to what muscle?

passes through BUCCINATOR and is lateral to the MEDIAL PTERYGOID
-if it goes posterior at level of mandibular foramen, it penetrates the PAROTID GLAND

185

most common cause of post-op hypotension?

how do you treat it?

anesthesia/analgesics on the myocardium

if it was from narcotics -> Narcan
if there is bradycardia -> atropine (anti-cholinergic)

186

vasovagal syncope is

how do you manage?

a psychogenic rxn (caused by psychological factors), most common complication assoc. with local anesthetics
-initial event is stress induced release of incr. catecholamines
-signs resemble shock, early sign is PALLOR (pale)

-put pt in supine position, legs elevated above heart (trendelenburg position), cool towel

187

most common cause of transient loss of consciousness in a dental office is

vasovagal syncope

188

3 drugs when given 1 hr before appt are safe to fearful patients

1. diazepam (valium)
2. promethazine (phergan)
3. pentobarbital (nembutal) or secobarbital (seconal)

189

hyperventilation in an anxious pt can lead to a __ spasm

carpodedal spasm (hand, thumbs, foot, toes)

190

a somatogenic reaction is

development of a rxn from an organic pathophysiologic cause

191

Shock symptoms include:

the main factor in all types of shock is __

the 3 stages of shock are:

symp - tired, sleepy, confused, cold sweaty skin, BP drops

main factor is reduced cardiac output!

1. compensatory stage - incr HR and peripheral resistance
2. progressive stage - metabolic acidosis
3. irreversible/refractory - organ damage

192

cardiogenic shock is most commonly caused by

myocardial infarction
-collapse from pump failure of the LEFT VENTRICLE

193

5 major types of shock

cardiogenic
hypovolemic
septic - from endotoxin from gram (-) bacteria
neurogenic
anaphylactic

194

the most abused drugs by dental professionals is

Meperidine (demerol)
-narcotic analgesic to releive pain, cough suppressant
-compares with MORPHINE

195

admin of meperidine and __ can cause life threatening hyperpyrexic rxns that can lead to seizures and coma

MAO-inhibitors

196

morphine causes

euphoria, analgesia, drwosiness, miosis, respiratory depression

197

2 tests that should be done before using a general anesthetic are

CBC
urinalysis (urine pH should be 6)

198

CBC includes 4 things

1. hematocrit - min is 30% for elective surgery
2. hemoglobin
3. total leukocytes (WBC)
4. total erythrocytes (RBC)

199

normal values for coagulation
template bleeding time = __ min
prothrombin time = __ sec
partial thromboplastin time = __ sec
platelets = __K/ml

1-9 min
11-16 sec
32-46 sec
140-440K

200

local contraindications to tooth extractions include

ANUG
irradiated jaws
malignant disease
acute infection with uncontrolled cellulitis
acute infectious stomatitis

201

systemic contraindications to tooth ext

-uncontrolled: diabetes mellitus, cardiac disease, dysrythmias, leukemias and lymphomas
-debilitating diseases
-severe bleeding disorders
-pts on immunosuppressives, corticosteroids, cancer chemotherapeutic agents

202

conditions that require abx prophylaxis prior to OS

1. prosthetic heart valve
2. rheumatic valve disease
3. most congenital heart malformations

NOT pacemakers cause endocardium isn't involved

203

standard prophylaxis for
amoxicillin?
clindamycin?

amox - 2 g
clinda - 600 mg

204

ideal time to remove impacted 3rd molars is when root is approx. how much formed?

2/3

205

complication most seen after ext of isolated max molare are

fracture of tuberosity or sinus floor

206

cavernous sinus thrombosis (CST) is usually caused by?

usually occurs in what vein?

late complication of an infection (staph aureus) of the central face or paranasal sinuses

OPHTHALMIC VEIN cause of absence of valves in angular, facial, ophthalmic veins

207

the most common neck space infection that involves the sublingual, submandibular, and submental spaces

Ludwig's Angina

208

submandibular space drains infxns from what teeth? where in relation to mylohyoid?

mand premolars and molars -> apices lie BELOW mylohyoid

209

sublingual space contains what gland

sublingual

210

submental space drains infections from what teeth? where in relation to mylohyoid?

medial part of submaxillary space
-drains from mand incisors and canines -> their apices lie ABOVE mylohyoid

211

most common site for supernumerary tooth is

maxillary incisor area, called a "mesiodens"

212

what Class lever is used for ext?

Class II
-teeth are ext by LUXATION perpendicular to long axis

213

luxation is

loosening of tooth by progressive severing of PDL fibers

214

what scalpel is used universally for all OS

#15

215

3 incisions used in OS

1. linear - for apicoectomies
2. releasing - do it at the LINE ANGLE
3. semi-lunar - for apicoetomies

216

suture sizing is based on 2 things

strength and diameter

smallest diameter should be used
ex. 9-0 has least strength and smallest diameter
3-0 and 4-0 are most common

217

most severe tissue rxn occurs with what kind of suture material?

plain catgut (resorbable - cause inflammatory rxn)

218

3 types of Resorbable sutures

1. plain gut - from sheep intestin, susceptible to rapid digestion
2. chromic gut - more resistant
3. polyglycolic acid - doesn't break down, more $

219

3 types of Non-Resorbable sutures

1. silk - multifilamentous, for INTRAORAL suturing
2. nylon - for FACIAL LACERATIONS
3. polypropylene - least likely to inflame

should remove in 5-7 days

220

what is the Caldwell-Luc approach

opening made into max sinus via incision into canine fossa above level of premolar roots

221

teeth are resistant to crush but are not resistant to __

shear
-> place forcep beaks parallel to long axis

222

what is the primary direction for extracting:
max primary/deciduous molars? adult max molars?

max primary/decid -> PALATAL

adult -> BUCCAL

223

genial tubercules are the attachment for what muscle?

suprahyoid
-on lingual surface of mandible
-NEVER excise cause if you did the tongue would be flaccid

224

dry socket is most common after ext what teeth

mandibular molars
-usually 2-4 days after tooth ext
-tx by flushing, place EUGENOL sedative dressing

225

pericoronitis assoc. with

crown of partially erupted tooth, most common with mand 3rd molar

226

5 phases of healing an extraction site

1. hemorrhage and blood clot
2. granulation tissue *GLUCOCORTICOIDS retard healing!
3. replacement of GT by CT and epithelialization
4. replacement of CT by fibrillar bone
5. recontour alveolar bone and bone maturation

227

3 stages of wound healing

1. inflammatory - vascular and cellular, neutrophils and lymphocytes predominate, macrophage is most important cell in healing!

2. proliferative (firbroblastic) - new collagen and blood vessels

3. maturation (remodeling)

228

what is the agent of choice to debride intraoral wounds?

3% H2O2

229

primary intention involves

both endosteal and periosteal proliferation
-little fibrous tissue is produced, with minor callus formation

230

secondary intention involves

mostly ENDOsteal proliferation
-lots fibrous tissue formed and callus is formed

231

greatest osteogenic potential occurs with what kind of graft?

autogenous cancellous graft and hemopoietic marrow

232

allogenic grafts (allografts or homografts)

SAME SPECIES

most common is FREEZE-DRIED bone, or freeze-dried decalcified bone

233

autogenous grafts (autografts)

SAME INDIVIDUAL

-most often used in OS
-to restore large areas of lost mandibular bones after surgery or trauma

234

bone marrow for grafting is usually taken from

the ILIAC CREST (also used for ridge augmentation)

235

isogenic grafts (isografts or syngenesioplastic grafts)

SAME SPECIES, but GENETICALLY RELATED

236

xenogenic implants (xenografts or heterografts)

ANOTHER SPECIES

not used in surgery

237

rejection of grafts is most common with these 2 types

ALLOgraft and XENOgraft

238

alloplastic graft

SYNTHETIC, tends to migrate from position where it was placed

239

hydroxyapatite is most commonly used for what procedure?

ridge augmentation
-when placed in a subperiosteal environment, it bonds physically and chemically to bone
-biocompatible, non-resorbable
-cons: migration, poor ridge form, abnormal color, mental nerve neuropathy

240

high speed turbine drills are ok/not ok?

TOTALLY UNACCEPTABLE
-tissue emphysema
-septic cellulitis

241

2 techniques for frenectomy

1. simple excision and Z-plasty - when it's narrow
2. V-Y plasty (localized vestibuloplasty) - good for lengthening, less scars

242

best way to enlarge prominence of chin is by

osteotomy - horizontal sliding

243

closed reduction is

closing the space btw a fractured bone without cutting through soft tissue or surrounding bone

244

systemic contraindications to elective surgery include

-blood dysplasias (hemophilia, leukemia)
-uncontrolled diabetes mellitus
-Addison's disease or any steroid deficiency
-fever
-nephritis
-cardiac disease (usually not within 6 months of infarction)

245

most common indication for tooth transplantation is severe decay of what tooth?

success is most predictable when roots are how much formed?

most likely cause of failure is what?

sequelae include?

1st molar (3rd molar placed)

roots 1/3-1/2 formed with open apices

failure with chronic, progressive EXTERNAL root resorption

sequelae -> ankylosis and root resorption

246

contraindications to implant placement include

-diabetes
-pituitary and adrenal insufficiency
-hypothyroidism
-tuberculosis
-sarcoidosis
-hx of uncontrolled bleeding

247

implants placed where have the highest failure rate?

maxillary anterior

248

3 types of bone-implant interface (integrations)

1. fibro-osseous integration - CT encapsulated implant within bone

2. osseointegration - most predictable long term stability, anchored into living bone

3. biointegration - hydroxyapatite or bioglass that bonds to bone

249

3 main groups of implants

1. endosseous - most common (80%), comes in 2 types
-root-form: cylindrical, most common
-blade-form (plate-form): when not enough bone

2. subperiosteal - below periosteum but above bone

3. transosseous - in atrophic mandible where root form could compromise strength of jaw

250

implant success requires

adequate transfer of force and biocompatibility

histo - 35-90% bone contact, CT adhesion above bone

clinically - no significant bone loss, no infxn, no mobility

251

4 types of biopsies

1. incisional - only part of lesion, a highly suspicious lesion

2. excisional - most often for oral lesions

3. needle - aspiration

4. exfoliative cytology - pap smear

252

what is the fixative used for routine biopsy?

10% formalin

253

biopsy indications

persists over 2 weeks, persistent hyperkeratotic changes, malignant characteristics, inflammatory lesion that doesn't respond to local tx in 2 weeks, persistent swelling

254

dentigerous cysts (primordial/follicular)

assoc. with crowns of unerupted tooth, result of degenerative changes in reduced enamel epithelium

255

eruption cysts

can incise or "deroof"

256

enucleation is

total removal of cystic lesion, used for congenital cysts, mucoceles, odontogenic cysts

257

marsupialization, decompression, partsch operation all create a __ in the wall of a cyst

surgical window, sac is opened and emptied

258

__ is the tx for ranulas, or a cyst large and close to vital structures

marsupialization

259

symptoms of dehydration

decr. BP
weight loss
incr. HR
CO
body temp
sunkey eyeballs

260

secondary pulmonary hypertension is most often caused by what condition

COPD

261

COPD disorders (4)

1. bronchial asthma - dyspnea and wheezing
2. emphsema - often with chronic bronchitis
3. bronchiectasis - purulent sputum, hemoptysis
4. chronic bronchitis - excess mucus, productive cough, assoc. with smoking

262

common results of chronic bronchitis

cor pulmonale - enlarged heart right ventricle, airway narrowing, squamous metaplasia

263

atelectasis

collapse of part or all of a lung
-most common anesthetic complication within first 24 hrs after general anesthesia
-prolonged can lead to PNEUMONIA

264

pneumothorax is

presence of air in pleural cavity

265

__ and __ are the 2 most common causes of fever in a pt who had general anesthesia

pneumonitis (lung inflamed)
atelectasis

266

asthma is a syndrome with these 3 symptoms

what drugs to avoid?

how do you treat acute asthma attack?

dyspnea, cough, wheezing

avoid: aspirin, NSAIDs, barbiturates, narcotics, erythromycin

tx -> inhale selective beta 2 agonist (terbutaline, albuterol) -> if doesn't work then EPI

267

most severe clinical form of asthma is

status asthmaticus
-airway obstruction can lead to respiratory acidosis -> death

268

hemophelia is

PTT is
PT is
bleeding time is

hereditary bleeding disorder, mostly males

PTT is PROLONGED
normal PT, BT

269

hemophelia __ and __ are sex linked recessive

A, B

A - factor VIII deficiency
B (christmas disease) - factor IX (plasma thromboplastin component) deficiency

270

hemophelia C (Rosenthal's syndrome) has a deficiency in

factor XI (plasma thromboplastin antecedent)

271

Von Willebrand's disease is inherited how?

autosomal dominant
-deficient in VWF (binding site for factor VIII, facilitates platelet adhesion to collagen for platelet plug)

272

most common cause of hemorrhagic disorders

3 ways this happens

thrombocytopenia, low platelets < 150K

1. decr. platelet production by bone marrow
2. incr. trapping of platelets by spleen
3. faster destruction of platelets

273

thrombocytopenia clinical features

purpuric lesions, nosebleeds, GI bleeding, urinary tract bleeding, severe hemorrhage

274

2 concerns when doing surgery on thrombocytopenia pts

post-op bleeding and
adrenal insufficiency

275

drugs that can potentiate bleeding after ext include

aspirin
anti-coagulants
broad-spec antibiotics
alcohol
anticancer drugs

276

best test to determine if OS can be safe on a pt taking coumadin

normal prothrombin time

277

this test detects coagulation defects of the intrinsic system, basic test for hemophilia

partial thromboplastin time (PTT)
normal is 25-36 sec

278

anti-coagulants include these drugs

pts will most likely have prolonged __ and __ times

dicumarol, heparin, antithrombin III, enoxaparin, warfarin

long PT and BT

279

__ and __ drugs inhibit platelet aggregation

apirin
NSAIDs

280

ecchymosis

hemorrhage into skin and subcutaneous tissue
-RBCs degrade, hemoglobin converted through bilirubin hemosiderin

281

most serious potential complication after ext on pt previously irradiated

osteoradionecrosis
-condition of non-vital bone

282

osteomyelitis is most often caused by what organism

in kids what bones, in adults?

staphylococcus aureus
-reduced blood supply predisposes bone to osteomyelitis

kids -> long bones
adults -> vertebrae, pelvis

acute osteomyelitis more common in mandibule because blood supply better in max.

283

ABC of CPR

airway
breathing - 12 breaths/min
circulation - 15 compressions every 2 breaths

284

if CPR is effective, the pupils will __

if you did too much pressure then what organ may be injured?

interrupting compressions can result in?

pupils CONSTRICT

can damage LIVER

less blood flow and BP drop to 0!

285

if normal BP cuff on obese pt, then reading will be low/high?

falsely HIGH

286

in congestive heart failure, what part of the heart fails first?

common CHF signs

left ventricle


signs - exertional dyspnea, paroxysmal nocturnal dyspnea (earliest and most common sign!), peripheral edema, cyanosis

287

what is given to manage pts with chest discomfort or possible MI?

nitroglycerin given sublingually

288

calcium levels are regulated by what hormone

parathyroid hormone
-if more PTH then bone resorption to increase calcium levels

289

low serum calcium will cause __ of nerves and muscles

hyperirritability

290

serum calcium is increased in these 4 conditions

1. hyperparathyroidism
2. chronic glomerulonephritis
3. hypervitaminosis D
4. multiple myeloma

DEcreased in diabetes mellitus

291

phosphorus conc. is regulated by what hormone?

parathyroid hormone
-increase in hormone cause increase in phosphate excretion -> decrease in plasma phosphorus conc.

292

in health, ratio of calcium:phosphorus in blood is

10:4

293

blood glucose conc. is regulated by __ and __

insulin and glucagon

294

serum glucose is increased in these conditions:

normal serum conc. of glucose is __ mg/dl

diabetes mellitus
adrenal tumors
incr. growth hormone
liver dysfunction

70-120 mg/dl

295

glucocorticoid secretion is stimulated by __ which is produced in the __

by ACTH, produced in the anterior pituitary

296

__ secretes 20 mg of hydrocortisone daily

adrenal cortex

297

pts on lots of steroids repress production of __

it takes how long to regain full adrenal cortical fxn?

ACTH -> atrophy of adrenal cortex

1 yr

298

erythema multiforme is a hypersensitivity syndrome charactereized by:

a severe form is called the __ syndrome

polymorphouse eruption, bullae and target "bulls eye shaped" lesions

severe form -> Stevens-Johnson Syndrome

299

Cushin's syndrome is caused by?

most common cause?

prolonged exposure of body's tissues to high levels of CORTISOL hormone

most common cause is pituitary adenomas

300

metabolic alkalosis major effect on body is

major causes?

tx?

over-excitable nervous system, can cause tetany (tonic spasm)

causes - diuretics, vomiting gastric acid, overactive adrenal gland (cushing's syndrome)

tx -> ammonium chloride

301

respiratory alkalosis major cause?

tx?

hyperventilation, liver cirrhosis, low oxygen in blood (high altitude), apirin overdose

LESS COMMON than respiratory acidosis

tx -> ammonium chloride

302

metabolic acidosis causes?

tx?

CNS depressed, disorientation, comatosed
-always during CPR

major causes - chronic renal failure, diabetic ketoacidosis, lactic acidosis, poisons, diarrhea

tx -> sodium bicarb

303

respiratory acidosis causes?

tx?

buildup of CO2 in blood

causes - hypoventilation, emphysesma, chronic bronchitis, severe pneumonia, pulmonary edema, astha

tx -> sodium bicarb

304

most common pancreatic endocrine disorder and metabolic disease invooving glucose and lipids

diabetes

305

classic triad of diabetes is

polydipsia
polyuria
polyphagia

306

how to tx hypoglycemia in UNCONSCIOUS diabetic?

CONSCIOUS diabetic?

unconscious -> IV injection of 50% dextrose in water

conscious -> admin of oral carb (eat)

307

#1 cause of kidney disease, 40% of kidney failures is

diabetes
(high BP is 2nd cause)

308

end stage renal disease (SRD) is when there is?

pts often taking what drugs?

permanent and almost complete loss of kidney function

-pts often on steroid therapy, more tendency for infxn and bleeding

309

whn tx pts with renal insufficiency and pts on hemodialysis you should

avoid drugs metabolized or excreted by kidneys

avoid NSAIDs (nephrotoxic)

do OS day after dialysis

310

rheumatic fever is an acute inflammatory disease with systemic manifestations and involved with heart valves, which foollows what infection?

how to tx?

group A beta-hemolytic streptococcus

NOT an infection, this is an inflammatory RXN to an infection

tx with penicillin

311

clinical dx of rheumatic fever when 2 criteria met.

what are the major jones criteria?

minor?

major jones - carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules

minor - fever, arthralgia, hx of rheumatic fever, EKG changes, lab tests

312

what valve is most commonly damaged from carditis resulting in rehumatic heart disease?

MITRAL (btw left atrium and left ventricle)

the pulmonary is rarely involved