Mucocoeles & Prescription Writing

1. Mucocoeles & Prescription Writing April 11, 2008

2. Mucocele • A patient presents with a lesion on the lip • The lesion is said to “go up and down” • The only thing it can be is a Mucocele • A mucous cyst (MC) is a benign, common, mucus-containing cystic lesion of the minor salivary glands in the oral cavity-(mucocele)

5. Mucocele • A mucocele can be created by • Trauma • Ortho Brackets • Anything that severs the duct of a minor salivary gland • The gland continues to produce saliva yet it has nowhere to go except into the connective tissue creating a Mucocele

6. Mucocele • The mucocele will rupture, then return • Surgical removal of a mucocele is never a guarantee • You may sever another duct and create a new mucocele

7. Mucocele • Do not distort the anatomy while anesthetizing for excision • Lasers will work very well for this type of procedure • In the absence of a laser: • Make a wedge-shaped incision around the mucocele and remove it without causing it to leak out • “Picking strawberries” you must remove all of the accessory glands once you’ve removed the initial large gland • Use the Adson Tissue Pick-ups to do this

9. Mucocele • A very large mucocele will be too large to excise completely • The procedure of choice in this circumstance is called Marsupialization • Open it up inside-out and let it granulate and destroy itself

10. Marsupialization • The surgical formation of a pouch to treat a cyst when simple removal would not be effective. • Under anesthesia, the cyst sac is opened and emptied. • Its edges are sutured to adjacent tissues, and a drain is left in place. • Over a period of several months, secretions will decrease and the sac space will be reduced until it is completely filled

11. Marsupialization • This technique involves the placement of a 4.0 silk suture through the widest diameter of the lesion (dome of the lesion) without engaging the underlying tissue. • A surgical knot is made, and the suture is left in place for 7 days. • Patients need to be educated about suture replacement; they must return to have the suture replaced if it should be lost during the 7-day period. • The idea behind this alternative treatment for mucoceles of minor salivary glands is that re-epithelization of the severed duct occurs or a new epithelial-lined duct forms, allowing egress of saliva from the minor salivary gland.

12. Hard Palate Lesion • Example of a pedunculated lesion on the lateral portion of the hard palate • Place a suture through the lesion and create tension • Incise to bone and remove entirely

13. Verrucous Carcinoma • Underside of tongue • Palpate to see how deep it is • When incising, follow the muscle pull (especially in the tongue) • It is the ONLY place in the mouth where you place extra knots due to the muscularity of the tongue • Make an Elliptical incision around the lesion  excise  Use Adson Tissue Pick-ups to remove the lesion muscular bed  sutures in to close • Only anatomy to be concerned about are the vein, and nerve in the posterior region

14. Epulis Fissuratum • Created by the body’s reaction to stabilize ill fitting dentures • The bone changes with repeated wear and the bone resorbs, creating more give, more space, and the body tries to fill the space in to make the denture more stable • The problem with granulation tissue is it is movable

15. Epulis Fissuratum • If you remove the epulis the tissue will relapse • After removal, suture the flap lower and extend the border of the denture to hold down the tissue • This will prevent loss of vestibular depth • Anything taken out, biopsy it because there is a 1% chance that it could be more than it seems

16. PDR • Physician’s Desk Reference (PDR) • Written by the manufacturers • All of the drug inserts placed in one book • Comprehensive indexing (4 sections) • Manufacturer index (Gray Section) • Generic/chemical index (non-trademark common drug names • Products/Category index (i.e. antihistamines) (Gray Section) • Color images of medications

17. Schedule III • Mix a peripheral acting analgesic with a central acting analgesic to avoid addiction • We don’t use Schedule II drugs in the clinic • When a patient comes in with a bombed out tooth and prefers drugs to extraction, they are a crack addict (PC) on the block

19. Narcotics • Schedule 3 drugs can be called in over the phone • Schedule 2 drugs CANNOT be called in • PERCODAN, PERCOCET, TYLOX • These are more potent • Narcotics are scheduled based on addiction potential • Vicodin is the most abused drug in country

20. Narcotics • Vicodin 5mg Hydrocodone and 500 acetaminophen • Vicodin ES (Extra Strength) 7.5 mg and 750 acetaminophen • If Vicodin 5mg doesn’t “work” take one and a half (like taking 7.5mg)

21. Vicodin 5mg

22. Vicodin ES 7.5mg

23. Narcotics • Tylenol with codeine • Review the handout • Aspirin and oxycodone • Percodan • Acetominophen and Oxycodone • Percocet, Tylox, etc • Synalgos DC • Aspirin, Caffeine, Dihydrocodeine

24. Tylenol #2 with Codeine 15mg

25. Tylenol #3 with Codeine 30mg

26. Tylenol #4 with Codeine 60mg

27. Percodan

28. Percocet

29. Tylox

30. Narcotics • ex: Synalgos DC • A synthetic narcotic • The only difference to Vicodin is that it is Tylenol based • Synalgos DC contains aspirin • Be careful with patients on coumadin or have bleeding ulcers • It has little bit of caffeine in it; DC=dihydrocodeine (synthetic narcotic) • Same equivalents

31. Synalgos DC

32. Narcotics • If the patient is allergic to codeine and is a drug addict, what do you give? • NSAID (like Motrin; Motrin 800-prescription-can only take 1 tab q6h prn pain; equivalent to Tylenol #3) • At night, a patient will call in and give a perfect academy award on phone to get narcotics • They’ve never been seen in practice • Give no one a narcotic, only a non-steroidal unless you know them for sure • They can take 4 OTC Motrin (each 200 mg) • They will be fine until can see them in morning

33. Prescription Writing • RX: What you are going to give patient • ex: Vicodin-500 mg less problems than with tylenol 3 like vomiting, diarrhea; this has synthetic codeine), cottage cheese or something to coat stomach  very FEW problems with vicodin • DISP: How many give patient • For a single tooth extraction  12 -15 enough); • When you go to Highland  write out the number (spell it!!) • Sig: What pharmacist translates into English for patient; • Pain pills dose at 1 tab q3-4h prn pain (q3-4 generally recommended for pain), dose every 3-4 then patient stay above the threshold and remains comfortable

34. Prescription Writing Alex Isom 867-5309 ? Eddy & Leavenworth Barely Legal Rx: Vicodin 5mg Disp: 12 (twelve) tabs Sig: 1 tab p.o. q3-4h prn pain

35. Motrin • 3200 mg/day maximum • Rx: Motrin 800mg • Disp: 20 • Sig: 1 tab p.o. q6h prn pain