Informed consent elements before root end surgery

INDICATIONS
•           Periapical cyst / granulomata (occurring as result of necrotic pulp due to trauma / dental carries)
•           Failure of orthograde root canal treatment
            Inaccessible apical third of the root
            Post / crown, tooth at risk of fracture with removal
•           Undiagnosed pathology around apex of tooth root filled / not root filled requiring biopsy

RATIONALE
•           Removal of tissue / cyst / pathological tissue, around apex of tooth
•           Amputation of root apex and placement of apical seal to prevent further infection
•           Pain relief

METHOD
•           Local or General Anaesthetic
•           Incise around neck of affected tooth with one or two vertical incisions diverging   into buccal sulcus
•           Reflect muco-periosteal flap to expose bone over apical third of root
•           Use rose head burr to expose root
•           Use fine rose head burr to divide apical third of root cutting flush with alveolar bone, bevelled to allow retrograde access to root canal.
•           Application of retrograde root filling
•           Irrigation and closure of flap (absorbable sutures)

BENEFITS AND ANTICIPATED OUTCOME OF PROCEDURE
•           Resolution of dental infection
•           Diagnosis of pathological lesions
•           Pain relief
•           Preservation of tooth
•           Restoration of normal function / form

RISKS / COMPLICATIONS ASSOCIATED WITH TREATMENT
•           Pain
•           Swelling
•           Bleeding
•           Failure of procedure with recurrent infection. 5-10% for anterior teeth. The risk of failure increases with multiple root teeth
•           Loosening / loss affected tooth
•           Damage / exposure of roots of neighboring teeth
•           Upper teeth: entry into maxillary antrum

ALTERNATIVES TO TREATMENT
•           No treatment
CONSEQUENCES OF PROPOSED TREATMENT

•           Removal of infection / source of infection
•           Diagnosis of disease – undiagnosed pathology
•           Pain relief
•           Retention of affected teeth
•           Return to normal function / form

CONSEQUENCES OF NOT ACCEPTING PROPOSED TREATMENT
•           Dental extraction

EXTRA ISSUES THAT PATIENTS MAY RAISE
•           GA: the procedure is usually undertaken as day case surgery, the patient being discharged the same day
•           Antibiotics, analgesia
•           Advice regarding oral hygiene/ mouthwash
•           Advice regarding time off education / employment
•           Healing in 7 - 10 days
•           No follow up appointment unless histology review required

ADVICE LEAFLET
•           Apical bone cyst

 Principles for restoration of youthful eyes

• Control of periorbital aesthetics by proper brow positioning, corrugator muscle removal, and lid fold invagination when beneficial. • Restoration of tone and position of the lateral canthus and, along with it, restoration of a youthful and attractive intercanthal axis tilt. • Restoration of the tone and posture of the lower lids. • Preservation of maximal lid skin and muscle (so essential to lid function and aesthetics) as well as orbital fat. • Lifting of the midface through reinforced canthopexy, preferably enhanced by composite malar advancement. • Correction of suborbital malar grooves with tear trough (or suborbital malar) implants, obliterating the deforming tear trough (bony) depressions that angle down diagonally across the cheek, which begin below the inner canthus. • Control of orbital fat by septal restraint or quantity reduction. • Removal of only that tissue (skin, muscle, fat) that is truly excessive on the upper and lower lids, sometimes resorting to unconventional excision patterns. • Modification of skin to remove prominent wrinkling and excision of small growths and blemishes

Healing of the Extraction Site

1. Day 1 – Clot formation
2. Day 2-7 – Granulation tissue fills socket
3. Day 4-20 – Connective tissue replaces granulation tissue; spindle cells, collagen fibers, and early vascularity is seen
4. Day 7 – Bone formation begins with uncalcified spicules and osteoid at the socket base and periphery
5. Day 20 – Mineralization begins
6. Day 40 – two-thirds socket filled with immature bone, lamina dura becomes lost
7. Day 50-90 – Bone matures into trabecular pattern resembling alveolus
8. Day 100 – Socket density comparable to surrounding bone, minimal residual osteogenic activity

                                                                                                                                   (Admin)

 Management of frontal sinus fractures

ACUTE MAYOR TRAUMA ALGORITHM- PRIMARY SURVEY

• Approach the patient from the side confirming that its safe to approach- shout for help.

1. AIRWAY + C-SPINE:

• Stand behind patient with your hands stabilizing the head (fingers apart so that they don’t cover the ears).
• Confirm who is your assistant and ask them to get you a c-spine head brace
• Inspection: airway obstruction- foreign bodies, facial, mandibular, tracheal, laryngeal fractures
• Put your cheek to their mouth and feel for any air movement.
• Interventions: if not breathing do a jaw thrust (will need both hands)
• Suction: to clear the airway of FB.
• Establish a definitive airway: orotracheal or nasotracheal intubation, jet insufflation, surgical cricothyroidotomy.
• Ask assistant for high flow oxygen: 15 litres/min through non- rebreathing (Hudson) mask (provides ~ 85% oxygen).

Indications for definitive airway:
Unconscious (GCS ≤ 8)
Severe maxillofacial fractures
Risk of aspiration (bleeding, vomiting)
Risk of obstruction

2. BREATHING + VENTILATION:

• Inspection: chest wall movement (symmetrical), chest injuries
• Palpation: bony deformities, fractured ribs, wounds
• Interventions: pulse oximeter
• Needle decompression (2^nd intercostal space MCL)
• Chest drain (5^th intercostal space mid axillary line)
• Seal open pneumothorax

Breathing problems identified in 1° survey:
Tension pneumothorax
Flail chest with pulmonary contusion
Massive hemothorax
Open pneumothorax


3. CIRCULATION + HAEMORRHAGE CONTROL:

• Level of consciouness, skin colour, pulse
• Inspection: colour (well perfused or pale), obvious haemorrhage
• Palpation: feel hands (warm or cold), capillary refill time
• Identify external bleeding- strongly palpate chest, abdomen, pelvis, long bones for haemorrhage
• Presence of pulses: carotid (SBP≥ 60 mmHg), femoral (SBP≥ 70 mmHg) and radial (SBP≥ 80 mmHg)
• Interventions: IV access- 2 litres Hartmanns for adult- BBC2- brown cannulae in both arms wherever you can get them. Take blood when put cannulae in for FBC, glucose. Blood transfusion
• Surgical intervention for internal bleeding
• Venous cutdown
• Chest drain: for massive hemothorax
• Pericardiocentesis: for cardiac tamponade
• Blood pressure, ECG

Injuries that acutely impair circulatory status:
External/internal bleeding with hypovolemic shock
Massive hemothorax
Cardiac tamponade


4. DISABILITY + DIABETES:

• GCS, AVPU for medical school
• Pupils: size, equality and reaction
• Blood glucose: pinprick for portable blood glucose monitor
• Interventions: burr holes (for trans-tentorial herniation), IV mannitol

5. EXPOSURE + ENVIRONMENT:

• Completely undressed the patient- prevent hypothermia- injured patients may arrive in hypothermic condition
• Log-roll and warmed crystalloid fluid

6. ADJUNCTS TO PRIMARY SURVEY:

• AP Chest and AP pelvic radiographs
• Urinary Catheter
• Gastric Catheter
• ABG
• DPL (Diagnostic peritoneal lavage) and FAST (Abdominal ultrasonography)
• Analgesia: morphine 10mg in 10ml after you have completed A-C

Pediatric Glasgow Coma Scale

Eye Opening

Best Motor Response

 Best Verbal Response

Classification of Nasal Fractures 

Nasal trauma Management algorithm