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Mucocoeles & Prescription Writing April 11, 2008 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) 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 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 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 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 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 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 reepithelization of the severed duct occurs or a new epithelial-lined duct forms, allowing egress of saliva from the minor salivary gland. 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 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 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 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 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 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 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 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) Vicodin 5mg Vicodin ES 7.5mg Narcotics Tylenol with codeine Aspirin and oxycodone Percodan Acetominophen and Oxycodone Review the handout Percocet, Tylox, etc Synalgos DC Aspirin, Caffeine, Dihydrocodeine Tylenol #2 with Codeine 15mg Tylenol #3 with Codeine 30mg Tylenol #4 with Codeine 60mg Percodan Percocet Tylox 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 Synalgos DC 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 Prescription Writing RX: What you are going to give patient DISP: How many 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 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 Prescription Writing Alex Isom Eddy & Leavenworth Rx: Vicodin 5mg Disp: 12 (twelve) tabs Sig: 1 tab p.o. q3-4h prn pain 867-5309 ? Barely Legal Motrin 3200 mg/day maximum Rx: Motrin 800mg Disp: 20 Sig: 1 tab p.o. q6h prn pain