Oral and Maxillofacial Surgery and Pain Control
Scope
This domain covers exodontia and minor surgery, complications, medical risk assessment, and local anesthesia. Know the indications for third molar removal: recurrent pericoronitis, caries, periodontal defects on the adjacent second molar, cyst or tumor, and associated pathology. Asymptomatic, disease-free third molars in a healthy patient are often monitored rather than removed.
Concepts to own
- Extraction mechanics: correct forceps and elevators, controlled force, and awareness of the inferior alveolar nerve and lingual plate in the mandible.
- Complications: bleeding (usually soft tissue or a vessel - manage with pressure, sutures, and hemostatic agents), dry socket (fibrinolytic, pain on days 3–5, treated with irrigation and a sedative dressing rather than antibiotics alone), infection, paresthesia, oroantral communication, and displaced roots.
- Anesthesia: inferior alveolar, Gow-Gates, Vazirani-Akinosi, mental, incisive, and greater palatine blocks; the inferior alveolar block fails more often in irreversible pulpitis.
- Local anesthetic dosing: 2% lidocaine is 20 mg/mL, so a 1.8-mL cartridge contains 36 mg. Limits are about 4.4–7 mg/kg, not exceeding 300–500 mg when epinephrine is included.
- Vasoconstrictor ceiling in significant cardiac disease is roughly 0.04 mg epinephrine, about two cartridges of 1:100,000.
Traps
Distinguish dry socket from osteomyelitis; antibiotics do not treat a dry socket. Remember that paresthesia is most frequent after mandibular third molar removal, and that bleeding in a hypertensive or anticoagulated patient needs pressure and, if needed, medical consultation rather than simply reversing medication.
Rule of thumb
Count cartridges before you inject: 36 mg of lidocaine each. Roughly 13 cartridges would reach 500 mg, but weight-based limits usually bind first.