Medical History
Pain History
● Pain = unpleasant sensory & emotional experience assoc w actual/potential tissue
damage
● S - site
● O - onset (sudden/gradual, progressive/regressive)
● C - character (sharp, dull, aching, throbbing)
● R - radiating
● A - associated symptoms
● T - time (how long does it last, when does it occur, does it keep you up at night)
● E - exacerbating factors (hot/cold/sweet) & alleviating factors
● S - severity (out of ten)
Dental History
● Regular attender
● Experience of dental treatment, any anxiety
- Symptoms of anxiety = nausea, pallor, nail biting, sweating, shaking, increased
respiratory rate, rapid heartbeat, fainting
● Experience of anaesthetic
● Oral hygiene routine
● Pain/clicking from TMJ, any bruxism
Social History
● To give a clear picture of lifestyle
● Job, alcohol intake, smoker, use of recreational drugs
Extra-Oral Examination
● Head & facial appearance: deformities, symmetry, CL&P, fractures
● Skin: lesions of face - colour, swelling, bleeding, crusting
● Eyes: proptosis (protrusion) / lid retraction
● Lymph nodes: submandibular, submental, anterior & posterior cervical, supraclavicular,
preauricular
● TMJ: palpate simultaneously - look for clicking, locking, crepitus
● Rima oris (oral entrance): small mouth can make surgery difficult
Intra-Oral Examination
● Oral hygiene, soft tissues, PD condition (BPE), chart teeth present, occlusion
Further Investigations
● Radiographs, sensibility tests, haematological investigations, microbial culture, general
obs, urine analysis, biopsy (incisional/excisional)
Clinical Assessment
Limited Access
● Severe TMJ disease
● Burn scars around lips
● Restricted view due to abnormal tooth position/crowding
● Displaced teeth → difficult to use forceps
● Partially erupted teeth require transalveolar approach
Older Age
, ● Denser, inelastic bone
● Greater risk of ankylosis
● Secondary dentine deposition → brittle teeth
Radiographic Assessment
Provide details on:
● Crown (presence/extent of caries)
● Root (size, number, shape, divergence, hypercementosis, ankylosis, resorption, #, pulp
vitality, presence of root filling/PR-crown)
● Angulation
● Surrounding bone (level, density, sclerosis, ankylosis)
● Anatomical structures (position of nerves & mx sinus)
● Adjacent teeth, impacted teeth, supernumeraries, odontomes
● Not always necessary (i.e. simple XLA)
Indications of Radiographs
● History of failed/difficult XLA
● Tooth abnormally resistant to removal w forceps
● Surgical removal planned
● Teeth in close proximity to other structures (nerves/sinus)
● All lower 8s
● All impacted, buried, displaced teeth
● Heavily restored/non-vital teeth
● Local/generalised bone disease suspected
● Traumatised teeth
● Lone standing upper molars
● Abnormalities of tooth development present
● Pts who have had jaw radiotherapy
Radiograph Selection
● Periapical (paralleling/bisecting angle), panoramic, oblique lateral
● Paralleling technique periapical: #1 normally, geometrically accurate, excellent resolution
(vs screen film), low dose (vs full panoramic)
● Panoramic RG: before XLA 8/multiple XLA, if large assoc disease (large cyst)
Stages of Inflammation
● Initial acute IF: may be no apparent changes / widening of RL line of PDL space [1] /
loss of RO line of lamina dura [2]
, ● Further spread of IF: area of bone loss at apex [3]
● Initial low grade chronic IF: no apparent bone destruction, but sclerotic bone around
apex (sclerosing osteitis) [4]
● Later stages of chronic IF: circumscribed, well-defined RL area of bone loss at apex,
surrounded by dense, sclerotic bone [5]
●
Consent
● Pt must be aware of: implication of no tx, adverse effects of tx, all available options
Control of Pain & Anxiety
Non-Pharmacological Control of Anxiety
● Tell pt there will be no pain, but lots of pressure/noises
● Maintain conversation, use distractions like background music
● Be flexible with TP (pt may not want all xtns in one go)
● Timing important - start less invasive tx first
Local Anaesthetic (LA)
Components
● LA agent = lidocaine hydrochloride
● Vasoconstrictor = adrenaline. Decreases blood flow to site of injection,
● Preservative = sodium metabisulphite
How LA works
● LA agents interfere w nerve conduction at site of axon membrane. Highly likely that
agents interact w specific receptor sites within membrane
● Reduce cell membrane permeability to sodium ions, but little effect on potassium ions
● Reduced influx of sodium ions → reduced degree of depolarisation → critical
threshold potential not reached → no action potential fired → no nerve
conduction
Which nerve & how much?
● Upper anteriors: anterior superior alveolar (teeth, PDL, buccal
gingivae/mucosa/supporting bone) & nasopalatine (palatal gingivae/mucosa/supporting
bone)
