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48 Cards in this Set

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Definition of a wound
any anatomical or functional interruption in the continuity of the tissue that is accompanied with cellular damage and death
Etiology of Wounds
Traumatic Injuries
Chemical
Physical
Pathologic
Cause disruption of tissues such as carcinomas and non healing ulcers(TB and Sarcodiosis)
Physical Injury-*
Crushing-rubber dam clamp
Extreme Temperatures
Irradiation-cancer patients
Dessication
Obstruction of arterial inflow or venous outflow-espeically in toes and fingers w/ diabetes and peripheral vascular disease
Denture irritaiton
Chemical Injury-*
-unphysiologic pH-very acidic or basic
-disrupt of protein integriy
-ischemia
-aspirin
-phenol
-arsenic and acids(ill-advised chemical consumption)
Healing definition
-Series of coordinated processes initated by injury and directed toward restoring structural and functional integrity
Types of Wound Healing
Primary-edges are put together-for soft and hard tissue healing(suturing)

Secondary-granulation tissue forms and epithelium migrates across to close up wound
ex. avulsed piece of tissue with too much tissue loss to close the wound-->formation of 2ndary healing

Tertiary Healing-delayed primary closure
ex. if wound is dirty, clean it out and then LATER freshen margins and close it to avoid sealing bacteria in
Primary Intention
-tissue?
-how to start it?
-scarring?
-how fast does it feal?
-used for?
-minimal tissue loss
-wound edges brought into contact with sutures
-minimal scarring
-rapid healing
-well repaired incisions and well reduced bony fractures
Secondary Intention
-wound edges?
-size of defect? filled with?
-scarring?
-healing?
-used for?
-Wound edges widely separated from surgery or tissue loss
-defect is large and filled with blood clot(starts healing process)
-scar formation, slow healing
-extraction sockets, avulsive injuries, poorly reduced bony fractures

- dont undermine gingiva and close via unattached mucosa
Tertiary Intention
Wound left open for period of time then closed with a tissue graft
Healing of Extraction Socket
-type of intention
-what happens inititally? for what reason?
what occurs during the first week? what happens in the wound?
-epithelium?
-sequence of events
-2ndary intention
-blood clot forms wihtin 24 hrs, coagulates and seals off from oral cavity

1st week: inflammatory phase + fibroplasia
-WBCs debride bacteria, bone, osteoclasts along wound margin


-epithelium migrates along socket wall until it reaches the other side

-2nd week: granulation tissue and new trabecular bone by osteoblasts-delay in pts with osteoporosis or bone problems

-4th week: epithelialization complete-may cause concerns in the anterior region

-4th week: new bone formation though poorly calcified-(refracture of bone is easy so must wait 6-8 weeks before physical activity)

-4-6 weeks: complete healing
Stages of Wound Healing
Inflammatory Stage-blood clot, inflammatory cells
Fibroblastic Stage(granulation tissue)-fibroblast come in, growth factor release, lattice network of soft/hard tissue laid down
Remodeling Stage-tissue becomes stronger or bone turns over to become lamellar rather than woven(which is initially formed during wound healing)
Inflammatory Stage
begins?
how long?
signs?
wound strength?
role of Fibrin?
-when tissue injury occurs
-3-5 days
-eat soft foods only and gentle brushing
-erythema, edema, warmth, pain, loss of fxn
-no gain in wound strength
-fibrin holds wound together-gets stronger in later stages
Inflammatory Stage-Vascularity
-immediate reaction?
-initiates?
-releases?
-vasoeffects?
-leukocytes
-max swelling occurs?
-vasconstriction immediate(maynot be possible with anticoagulants)

-clotting cascade from veseel disruption

-Mediators: Serotonin, Histamine, Prostaglandin

-Vasodilation and increased vascualr permeability

-leukocytes(debride) adhere to endothelial cell wall, migrate to interstitial tissues-->edema(max swelling48-72 hrs post procedure...1 week for large surgery)
Cardinal Signs of Inflammation
Warmth and erythema-->vasodilation

Swelling-->leakage of fluid

Pain and loss of fxn--> release vasoactive amines and pressure from edema

note: vicodin may not be as effective as antiinflammatories if inflammation is the reason for pain
Cellular Componenet
-triggered by?
componenets
-activation of complement

-C3, C5 chemotactic factors
-neutrophils-initial
-macrophages-debride + growth factors for healing
-lymphocytes
Neutrophils
-how soon do they appear?
-mechansim
-fxn
-first cells that appear
-6-12 hours
-release lysosomal enzymes(proteases)
-digest necrotic debris and bacteria
Macrophages
-type of cells
-fxn?
-attracted by?
-release?
-phagocytic cells
-continue debridement
-chemoattractants, fragments of collagen, TGF-B1, thrombin(lattice of fibrin to strengthen wound)
-release biologically active substances like pgs, lks, gfs
Growth Factors
-necessary for?
-secreted by?
-examples
-necessary for inititiation and propagation of granulation tissue
-secreted by macrophages
-PDGF, TGF-a, TGF-b, EGF, FGF
Lymphocytes
-mostly found in?
-tcell function?
-T and B cells are found in chronic inflammation
-can cause serious dammage in PA lesion or endodontics

-T-cells secrete lymphokines, chemotactic for fibroblast proliferation
ECM
-how much?
-what holds the wound together?
-little ECM present
-only fibrin holds wound together at this stage
-fibrin scaffold for fibroblasts to lay down ECM in granulation tissue phase
Fibroblastic Stage(Granulation Tissue)
-timing
-what forms
-vascularity?
-type of wound healing
-what do you see?
-2-3 weeks-wound starts to strengthen

-Fibrin scaffold

-Collagen deposition

-revascularization

-haphazard wound healing

-macrophages, fibroblast ingrowth, loose connective tissue, angiogenesis
Wound Contraction
-occurs at?
-presents significant amounts of?
-what happens to fibroblasts
-how to reduce this?
-what happens to the wound?
-movable wound edges
-granulation tissue
-fibroblast phenotypic changes during wound contraction
-inhibit granulation tissue reduces contraction such as skin grafts
-reepithelialization and contraction close wound
Remodeling Stage(maturation)
-timing?
-begins with?
-physical changes?
-scar changes?
->3 weeks
-begins with remodeling

-increase in tensile strength
-not really possible to tear up wound after this
-reorganization of collagen-not as haphhazard

-scar softens and contracts
-can massage
Abnormal Scar Formation
-Hypertrophic scar
-scars usualy present as
-HT presents as
-Keloid
-presents as
-common in
-occurs in people
-how to prevent this?

neither happen intraorally
-Hypertrophic
-scar is usually flat w/ less pigment than tissues surrounding area
-raised and pink-ish

Keloid
-extra piece of tissue that proliferates and grows out
-common in asian/african americans
-often shows up in the past-some people more prone
-try intraoral approach to prevent this
Surgeon's goal
to produce a scar that minimizes loss of fxn and looks as inconspicous as possible
Factors that impair wound healing
-foreign material
-necrotic tissue
-ischemia
-tension-causes tissues to become ischemic(decreased vascularity and thus healing)
Bone Healing and Repair types
Direct
Indirect
Direct Bone Healing
-contact?
-distance?
-kind of healing
-relies on what type of fixation
-type of bone deposition
-extent of callus?
-what is found in the area?
-edge to edge contact
-< 1mm
-cellular healing
-rigid bone fixation
-Direct lamellar bone deposition
-minimal callus formation
-osteoblasts, haversion canal, osteoclasts
Indirect Bone Healing:
-type of callus
-pathway
-what forms?
-effect mobility has on healing
-collagenous bridging(callus)

- hematoma-->inflammatory phase-->granulation tissue--?fibrous tissue--?fibrocartilage callus-->cartilage-->osteoid tissue

- woven bone forms by endochondral ossifcation

- poor bone formation-->mal-union of bone-->negatively affects occlusion in jaws
Adequate Bone Healing needs?
-vascular supply-nourishment and oxygen supply

-immoblization-slight tension to sitmulate continued osteoblastic proliferation and ossification
Complications of Bone healing
-nonunion(not immobilized, not enough vascularity, segment too long)
-failure of fracture to heal
-infection
-osteomyelitis(hard to tx b/c hard for antibiotics to penetrate into bone)
Implant Osseointegration

-effect on epithelium
-what must happen on implant surface?
how long does it take for full integration?
-bone-implant interface inhibits lateral growth of epithelium without contact inhibition

- bone healing onto implant surface must occur before soft tissue forms
-want bone surrounding entire implant
-6 months needed for full integration
-but now can put crown immediatley on and load it
implant OI
-distance between bone and implant
-need what kind of bone near the implant
-why do you need a nightguard/splint
-surface needs to be free of?
-short distance b/w bone and implant

-viable bone at or near surface of bone along the implant
-can do bone graft or put implant deeper

-no movemment of implant while bone is attaching to its surface

-implant surface free of contamination by organic/inorganic materials
IO be careful of
excessive loading
Factors Affecting Healing
IF DINAR

- Infection
-Foreign Material

-Diabetes
-Ischemia(hypoxia)
-Nutrition(protein and vitamin deficiency)
-Age
-Radiation
Bacterial Infection
-role in healing?
-what does it do?
-sxs?
-releases?
-major cause of impaired healing
-colonization with inflammation leads to further tissue damage
-redness, heat, edema, pain, leukocytosis, fever
-release of proteases and oxygen free radicals, cell lysis, destruction ECM, impaired healing
Ischemia(hypoxia)
-how does it impair healing?
-what leads to ischemia
-causes?
-decreased O2 impairs healing

-constricting sutures, tissue edema, necrotic tissue
-anemia(not as much blood to tissues), malnutrition, sepsis lowers tissue oxygen

-cell death-->release proteases and glycosidases
-tissue breakdown and impaired healing
Radiation
-dependent on?
-type of effects?
-how is it damaging?
-dose depdendent
-acute and chronic effects
-Acute-->mucositis, erythema, desquamation
-Chronic-->irreversible, in vessel walls, skin connective tissues and mucosa

-osteoradionecrosis of bone
radiation effects do not get better with time but get worst due to lessening of blood supply
Age
-more susceptible to wound healing problems
-decline in general health
Therapeutic Agents
detrimental?
what stimulates healing?
what do chemotherapeutics do?
can possbily arrest?
- detrimental effects on health
-steroids, anticoags, antineoplastics

-growth hormone, Vitamin A and C stimulate healing

-chemotherapeutics inhbit wound repair
-decrease tensile strength

Arrest inflammatory phase
-suppress protein synthesis and cell proliferation
malnutrition
-role in wound healing
-good nutrtion does what?
-greatest contributor to poor wound healing, esepcially in elderly

-enhance immune response
-stimulate hormone secretion