How to prevent excessive bleeding during Dentoalveolar Surgery❓

Types of bleeding are:

  1. Primary (during or immediately after surgery)
  2. Reactionary (Upto 48 hours due to a defective suture or as clot in the vessels has got disturbed)
  3. Secondary (8-14 days due to wound getting infected and capillaries have eroded surfaces)

To prevent excessive blood loss during surgery we need to understand the source of bleeding i.e. possible reason for bleeding.


Dr. Mehnaz Memon🖊

Malaria (Features of P.falciparum infection)

P.falciparum infection

🤒Clinical Features:

This is the most dangerous of the malarias and patients are either ‘killed or cured’. The onset is often insidious, with malaise, headache and vomiting. Cough and mild diarrhoea are also common. The fever has no particular pattern.

🦗Neurological

  • Coma
  • Hypoglycaemia
  • Seizures
  • Cranial nerve palsies
  • Opisthotonus (a type of abnormal posture where the back becomes extremely arched due to muscle spasms)
Disconjugate gaze due to cranial nerve palsy

🦗Optic fundi

Malaria Retinopathy with Roth’s spots

🦗Respiratory

  • Pulmonary edema
  • Secondary bacterial pneumonia

🦗Cardiovascular

  • Shock
  • Cardiac failure (‘algid malaria’)
  • Dysrhythmias with Quinine

🦗Renal

  • Acute renal failure
  • Severe haemolysis results in haemoglobinuria (black water fever)

🦗Abdomen

  • Hepatic dysfunction & haemolysis lead to Jaundice
  • Tender liver edge with hepatitis
  • Pain in left upper quadrant with splenomegaly

🦗Blood

  • Parasitaemia
  • Anaemia – Normocytic Normochromic
  • Thrombocytopenia
  • Coagulopathy
Ring form in RBC

Dentowesome 2020

@dr.mehnaz🖊


References: Davidson’s Principles and Practice of Medicine Textbook; Image source: ResearchGate, Quizlet

INFECTIVE ENDOCARDITIS

Indications for cardiac surgery in Infective Endocarditis:

🔅 Heart Failure due to valve damage
🔅 Failure of antibiotic therapy
🔅 Large vegetations
🔅 Abscess formation

Dr. Mehnaz Memon🖊


References: Davidson’s Principles and Practice of Medicine Textbook

CHRONIC MYELOID LEUKEMIA

Leukemias are malignant Neoplasms of the haematopoetic stem cells characterized by diffused replacement of bone marrow by Neoplastic cells with or without involvement of the peripheral blood.

➡️ Chronic leukaemia is a disease of insidious onset, affecting middle aged & young adults (CML)

🔅CLINICAL FEATURES:

  1. Gradually developing Anaemia
  2. Hepatosplenomegaly (In CML, a massive splenomegaly reaching upto the umblicus) Therefore, acute pain due to splenic infarction
  3. Bleeding tendencies
  4. Hypermetabolism
  5. Bone pain
  6. Juvenile CML: Lymph node enlargement, frequent infections, haemorrhagic manifestations & facial rash

🔅LAB. FINDINGS:

  • Thick and sticky & shows a wide buffy coat in the haematocrit tube
  • Anaemia – Moderate, normocytic normochromic
🔘 1 lakh - 5 lakh/cu.mm

🔘 Differential count reveals more mature forms in Peripheral smear, complete spectrum of granulocytes, myelocytes & band cells (50%)

🔘 Blast cell > 10% of leukocytes

🔘 Phases:

1. Chronic phase:

➡️ Myeloproliferative disorder – excessive proliferation of myeloid cells & mature segmented Neutrophils

➡️ Basophils upto 10% (feature of CML)

2. Accelerated phase:

  • ⬆️ Anaemia
  • Blast count: 10-20%
  • Basophils: 20%
  • Platelet: ⬇️ 1 lakh/µl
  • Leucocytosis

3. Blastic phase: Myeloid blast crisis in CML resembles AML >20%

  1. Cellularity: Hypercellular fat spaces replaced by Myeloid cells.
  2. Myeloid cells: ⬆️ M:E ratio
  3. Erythropoiesis: Normoblastic
  4. Megakaryocytes: Conspicuous, smaller in size
  5. Chromosomal abnormalities: The philadelphia chromosome is present in about 90% of the cases of CML

• neutrophil alkaline phosphatase (NAP) activity is markedly reduced in CML

🔅TREATMENT:

  • The standard treatment for chronic phase CML is a tyrosine kinase inhibitor (TKI) like imatinib oral therapy. Imatinib works by reducing the production of abnormal white blood cells.
  • Allogenic bone marrow transplants.
  • Interferon was once the best treatment for CML, but now, the tyrosine kinase inhibitors are the mainstay of treatment and interferon is rarely used. To treat CML, this drug is most often given as a daily injection (shot) under the skin. It may also be injected into a muscle or vein. It’s given for many years.
  • Chemotherapy: Today, chemo may be used to treat CML when the TKIs have stopped working. It’s also used as part of a stem cell transplant.
  • Others:
  • Splenectomy
  • Splenic irradiation
  • Leukapheresis

🔘 Splenectomy and splenic irradiation have been used in patients with large and painful spleens, usually in the late phase of CML. This is rarely needed in patients whose disease is well controlled.

🔘 For those patients unable to tolerate chemotherapy, leukapheresis is a viable option.

Dr. Mehnaz Memon🖊


References:

  1. Textbook of Pathology, Harsh Mohan; Internet articles
  2. Image source: Google

APERT SYNDROME

🔖 Acrocephalosyndactyly. The condition is autosomal dominant i.e, one copy (out of 2) of the defective gene is sufficient to cause the abnormality in the offspring.

🔹Characteristics:

  • Craniosynostosis (premature fusion of the skull bones)
  • Craniofacial anomalies
  • Syndactyly (Fusion of fingers and toes)

🔹Etiology:

🔹What are the Symptoms and Signs of Apert Syndrome?

The various clinical features include:

  1. Asians affected
  2. Acrocephaly, Brachycephaly, flat occiput & prominent forehead.
  3. Late closing fontanels
  4. Low set ears, hearing loss
  5. Eyes: Down slanting of palpebral fissures, Widely spaced eyes(Hypertelorism), Shallow orbits, Abnormally bulging eyes (Exophthalmos)
  6. Nose: Depressed Nasal bridge, short, wide with bulbous tip, Parrot beaked appearance, Atresia
  7. Jaw:
  • Prominent Mandible
  • Maxillary hypoplasia
  • Drooping angles of mouth
  • High arched palate
  • Bifid uvula
  • Cleft palate
  • Crowded upper teeth
  • Malocclusion
  • Delayed & ectopic eruption
  • Shovel shaped incisors
  • Supernumerary teeth
  • V-shaped maxillary dental arch
  • Bulging alveolar ridges

8. Partial to complete fusion of digits: 2-4th digits – MITTEN HANDS & SOCK FEET; Sole – supinated

9. Intelligence – Normal

10. ⬆️ intracranial pressure – optic atrophy, papilledema

11. Hyperhidrosis

12. Cardiovascular system: Atrial Septal defect, Ventricular septal defect, Patent ductus Arteriosus

🔹How do you Treat Apert Syndrome?

Standard Therapies

The treatment of Apert syndrome aims at addressing the specific symptoms that may be present in the particular individual. Treatment is usually symptomatic and supportive.

  • Craniosynostosis and associated hydrocephalus in some cases may give rise to an abnormally increased pressure within the skull (intracranial pressure) and on the brain. In these cases, early surgery (within 2 to 4 months after birth) becomes necessary to correct the defects in the skull and facial bones.
  • Insertion of a tube (shunt) to drain excess cerebrospinal fluid (CSF) away from the brain and into another part of the body like the abdomen where the CSF can be absorbed can be done to relieve associated hydrocephalus (fluid accumulation in the brain).
  • Early repair and reconstructive surgery may also be done in some infants with Apert syndrome to address craniofacial abnormalities.
  • Other defects such as those of heart, eye and ear defects may also need correction.

Dr. Mehnaz Memon🖊


References:

  1. https://www.medindia.net/amp/patientinfo/apert-syndrome.htm
  2. Shafer’s textbook of Oral Pathology – 7th Ed.

Minimal Invasive Dentistry

current approach in dentistry in Covid state

Amidst the pandemic state with the high transmissibility of the disease through air & droplets and considering that routine dental procedures usually generate aerosols; alterations to dental treatment is of prime concern to maintain a healthy environment for patient & dental team.Here is where the approach of performing minimally invasive dental treatment becomes crucial.

Risks of infection – Human-to-human transmission

What is minimal intervention dentistry?

Minimal intervention dentistry( MID) is a conservative philosophy of professional care concerned with first occurrence,early detection & earliest possible cure of caries at a micro level ; followed by minimally invasive and patient friendly treatment to repair irreversible damage caused by dental caries.

Goals & Principles:

.Early diagnosis of dental caries

.Assessment of individual caries risk

.Disease control by remineralisation of incipient carious lesions.

.Repair rather than replacement of defective restorations

.Minimal invasive treatment

.Periodic follow up.

Caries diagnosis:

Includes early diagnosis & caries risk assessment

Early diagnostic aids
Factors relevant in caries risk assessment

Procedures:

Non invasive procedures: Biological approach

Remineralising agents

Minimal invasive treatments:

1)Air abrasion

Indications-

.for abrading the surface of old composites prior to new restoration ; minimal class I & class II preparations for composites ; for abrading ceramic or cast restorations for bonding ; for widening pits & fissures for sealants.

2) Sono Abrasion

Indications-

.opening pits & fissures for sealant restorations ; minimal preparation of incipient class II cavities

3) Chemicomechanical Caries Removal (CMC)

Carisolv – 2 syringe system ,one containing NaOCl & other with 3 amino acids (glutamic acid,leucine ,lysine); carboxymethylcellulose gel;NaCl,NaOH;Erythrosine.The contents are mixed together to form a pink gel which is applied onto carious dentin and left in place for 30 seconds to allow it to soften & degrade the infected dentin.

Advantages – relatively painless, removes only carious dentin, no vibrations,better substrate for adhesive bonding

Disadvantages- expensive, time consuming

4)Enzymes

5)Laser

2 commonly developed lasers-

.Er:Cr:YSGG(2780 nm)- Erbium,Chromium,Yttrium,Scandium,Gallium,Garnet laser – works by agonizing water droplets as they travel towards the target tissue.

.Er:YAG(2940nm)-Erbium,Yttrium,Scadium,Aluminum,Garnet laser – uses pulses of light energy to micro vaporize water within the target tissues.

6)Ozone

Caries treatment with ozone – based on Niche environment theory .Ozone kit consists of portable apparatus & disposable silicon cups. Follow up 3-6 months.

Disadvantages – can cause porosities or abrade tooth surface ,in case of heavy exposure.

Other techniques (in brief):

7)Atraumatic restorative treatment (ART)

8)Rotary instruments

Cavity designs for minimal tooth preparation:

According to the new classification based on site,size & severity of lesion,following are the designs –

Pit & fissure sealants;Preventive Resin Restorations (PRR)
Tunnel preparations
Slot preparations

Restorative materials used in minimal invasive dentistry :

Conclusion:

Minimal intervention techniques cause less tooth destruction than conventional techniques,thus increasing the long term survival of teeth ,also cause less discomfort to the patient and ensure healing of the disease not only the symptoms. With a reduction in chair side time and simplified techniques there is lesser chances of exposure of the dentist to aerosol contamination,thus maintaining which is the need of the hour.

BURKITT’S LYMPHOMA

🌏 African Jaw Lymphoma

🌏 The endemic form is linked to malaria and to the Epstein-Barr virus (EBV), a common virus that also causes glandular fever.

🌏 A tumour peculiar to children of central Africa was reported by Denis Burkitt in 1950. It is a lymphoreticular cell malignancy.

▪️It is a high grade B-cell neoplasm & has 2 major forms:

🔷 Clinical Features:

1. Age – between 6 & 9 years

2. Sex – M:F – 2:1

3. Site: In African form (Endemic),

  • Maxilla > Mandible
  • Spreads to floor of orbit
  • Molar area
  • More than one quadrant is involved

American form (Non-endemic) – Oral: only 1 quadrant involved. Other: Mainly involves Abdomen.

4. Onset & progress – fast growth with tumor doubling time of <24 hours.

5. Symptoms –

  • Swelling of jaws, abdomen & paraplegia
  • Loosening of teeth
  • Abdominal tumors
  • Bowel obstruction

6. Sign – Lymphadenopathy (Non-tender)

🔷 Oral Manifestations:

  • Gingiva and mucosa – swollen, ulcerated, necrotic
  • Facial asymmetry
  • Teeth are pushed out of their sockets

🔷 Radiographic Features:

🔷 Histological Features:

1. Monoclonal proliferation of B-lymphocytes characterized by small non-cleaved cells.

2. Burkitt cells are homogenous in size & shape with –

  • round to oval nuclei
  • coarse chromatin
  • Multiple nucleoli
  • Basophilic vacuolated cytoplasm with neutral fat

🔷 Differential Diagnosis:

  • Non-hodgkins lymphoma
  • Cherubism
  • Osteosarcoma

🔷 Treatment: Intrathecal Chemotherapy

References: Shafer’sTextbook Of Oral Pathology


Dr. Mehnaz Memon🖊


Ann Arbor Staging System for Lymphoma: https://dentowesome.wordpress.com/2020/06/15/ann-arbor-staging/