Кафедра / Стоматопедия
Ортопедической стоматологии
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Главная Methodical work 4 курс, 8 семестр Prosthodontics in emergencies. 

Prosthodontics in emergencies.

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1.Topicality:In modern dental practice the issues of adverse events (emergency conditions)remain topical. Complexity of the problem is related to specific characteristics of outpatient reception. Maxillofacial region is a powerful reflexogenic zone andneedsadequate anesthesia supplement, which is not always achieved.Therefore, patients aafraidtobestomatologically interventedwhich increases sensitivity to pain. There are changes in the nervous and hypothalamic-pituitary-adrenal system, that reveal adverse reactions.

2.Workshop objectives

2.1. General objectives. Familiarize students with possibility of emergency conditions and providing emergency medical care.

2.2. Educational goal. Familiarizestudentswith experience ofdoctorsand scientific developments in treatment of emergency conditions.

2.3 Specific objectives1. know the mechanism of complications and rendering emergency aid..

2.4. .Based on theoretical knowledge of the topic

1. to be able to provide emergency medical assistance depending on the patient’s state.

 

3. INTERDISCIPLINARY INTEGRATION

Disciplines

To know

To be able to

1

2

3

4

I.

Previous discipline

1. Anatomy of the maxillofacial area.

2. Physiology ofa human

 

the structure of maxillofacial area.

Endocrine system

 

II.

The following disciplines

1. Dental Surgery`

clinical picture of emer-

gency conditions

 

III.

Inner integration of the field

 

Mechanism of formation of the given situation in apatient

Render medical assistance depending on the symtoms of complification

4. Topic contents :Risk factors of some common somatic diseases

(byE. V.Zoryan with co-authors, 1997)

1. Heart failure.Increased secretion of adrenaline as a result of stress reactionboth use of adrenaline as part of anesthesia medicines may lead to to acute cardiac decompensation. For patientsthattakecardiac glycosides, adrenaline can trigger cardiac arrhythmias. Incaseofdisturbedcirculation, development of necrotic processes in the mouth ispossible evenwhentraumatism andquantityofstomatologicalinterventionwasslight.Prevention: perform outpatient dental intervention withpatientfeelingsatisfactory, in other cases provide assistance only in a hospital. With clearly marked heart failure with the threat of decompensation (shortness of breath at rest) the possibility of dental treatment is to be decided with a the patient's doctor therapist. Be careful when choosing a medication for pain relief (use local anesthetic without epinephrine or with a minimum of its contents).

2. Coronary heart disease.Fear or pain during dental intervention or use of adrenaline in solutions of local anesthetic, may provoke an attack of angina and the development of myocardial infarction.Prevention:If the patient's condition is unstable (precordial pain orpain behind the breastbone is calm), dental treatment is to be decided with a the patient's doctor therapist.. if necessary, give the patient a usually dose of nitrate. It is reasonable to do drug training with sedatives before treatment. When doing local anesthesia use themedications, thatdon’tcontainadrenalineor use vasopressinand felipressin asavasoconstrictor in local anesthetics. Injecttheanestheticnomorethan1 carpule(1,8 ml). control the level of blood pressure duringtreatment.After patient's acute myocardial infarction during the first six months because of the risk of relapse to held only urgent dental intervention in the hospital with anesthesiologist and cardiologist.

3. Cardiac arrhythmia (disturbance of frequency and rhythm of heartbeats). in case of tachycardia, stress or the use of anesthesia solutions, containing adrenaline, may cause a heart failure. If patient hasbradycardia, use of local anesthetic may provoke the a complete atrioventricular block.Prevention.Beforedentaltreatmentoneshoudcheckthepatient’spulse, measurehisbloodpressure, conductdrugpreparationwithsedativesand provide an adequate anesthesia with anesthetics that do not contain adrenaline.If the patient's heart rate is below 50 beats per minute and there is an atrial fibrillation, extrasystoles, the choice of anesthesia should be chosen after consulting a therapist.

4. Hypertension (consistently high BP,  systolic pressure over 145-160 mm or diastolic over 95 mm of mercury). While being treated by a dentist,the patient may experience a hypertensive crises or acute heart failure. Prevention. Providepremediactionwithsedatives, regulateBPwiththehelpofmedicines, an adequate anesthesia with anesthetics that do not contain adrenaline. Ifnecessaryoneshouldusepreparations that contain adrenaline in concentration of 1:200000 (UltrakainDS) andlowerwith precautions for intravascular injection (aspiration test). 

5. Hypotension.DecreasedBP (systole is less than110mm for men and 100 mm for Women, diastole is less than 65 mm.).During the dental intervention one may experience fainting, collapse, shock and use of sedatives could further reduce BP.Prevention.Beforethetreatmentwithmedication, adjust blood pressure, inject atropine sulfate 0,1% or metatsyn sulfate 0.1%up to1 ml depending on heartbeat rate and BP. All dental manipulation aretobedoneafterlayingthepatienthorizontally. While trating one must control patient’s blood pressure.

6. Bronchial asthma.During the dental intervention one can have an asthma attack.because of excitement. Medicationsandmaterialswithwith strong smell maycausebronchospasm. Prevention. Consultation by theraputist. Detailed history taking to identify allergens,that provoke bronchospasm. On the day of treatment recommend the patient to take commonly used medications і bring an appropriate medical nebulizer or inhaler. Local anesthesia is thepreffered type of anesthesia. With heightened sensitivity to Sulphite neveruselocal painkillers withvasoconstrictor because of the fact that they contain bisulfite as a preservativeof vasoconstrictor. Do not use acetylsalicylic acid (The danger of so-called "aspirin asthma")and other medications, that provoke bronchospasm (morphine, indomethacin).

7. Allergic conditions.Patientsthatturntothedentistoftenhaveallergic reactions in theirmedicalhistory, including the ones on local painkillers. Themostfrequenttypesofalergesareallergies to local anesthetics (especially groups ofesters likenovocaine), and the ones that are preservatives in carpules, vials (Parabens, sodium bisulfite, etc.). Moreover, allergic reactions can becausedbyantibiotics, sera, dental materials etc.On contacting the allergen an allergic reaction brakes out until development of anaphylactic shock.Prevention.Careful history taking to identify allergic reactions. Particular attention should be given to patients, thatsufferfromallergic and infectious-allergic diseases (rheumatism, collagens, asthma, eczema, etc.) Don’t use the medications that were spotted to cause allergic reactions. If necessary, send the patient for the consultation to the allergy diagnostic department. Useantigіstamіnnі drugs or hormonal agents (prednisolone, hydrocortisone)aspremedication.

8. Anticoagulationtherapy.Incasethepatienthasaincreased tendency to clot (inpresenceofangina, vascular prostheses, heart valves, etc.) inordertoto prevent thrombosis, the ability of blood to clo is reduced by drugs Heparin, antagonists of vitamin D.).After the operation (Incision, tooth extraction, etc.) bleeding, hematoma formation may appear.Prevention.Pall attention to blood (duration of bleeding, clotting time, etc.).. If the basic parameters of blood coagulation are of appropriate limits, then, after consultation with the therapist, the patient can have tooth extraction, incision of abscess. More complex operations need to be performed only in stationary conditions after correction of clotting. Exclude medications that increase the effects of anticoagulants (Aspirin, fenilbutazon, macrolides and tsefalosporyns).

9. Епілепсія.An attackof convulsive syndrome can occur in a stressful situationas a result of using local anesthetics.Prevention.Careful history taking to identify convulsive attacks.consultation with the therapistof the patient. On the day of treatment at the dentists the patient ought to takethemedications that he usually needs. Do drug training with sedatives before treatment. Incaseofoftenepilepticseizuresdental interference is to be done during the period of the least density of attacks in a multidisciplinary hospital with resuscitator-anesthesiologist, neurologist. Itisrecommendedtouselocallocal anesthetics of Articaine group (ultrakainDS ultrakainDS-forte, septanest) as they are the most effective.

10. Glaucoma.Adrenaline expands the apple and can trigger an acute attack. Prevention. Local anesthetic drug should not contain adrenaline. For composition of sedation avoid atropine and other M-cholino blockers.

11. Diabetes.dentist must remember the possibility of such patients getting into coma. This may be due to release a large number of blood adrenaline, insulin, which is an antagonist that leads to the development of hyperglycemic coma After surgery, as a result ofangiopathy, reduction of immunological properties of the bodyoccur, observed slow wound healing and development of infection. AsaresultofDisseminated intravascular coagulation diabetics are observed to have early and late bleeding after surgery.Prevention.Before dental interventions of patients with diabetes an advice of endocrinologist is needed.Attentionshouldbepaidonblood and urine analysis concerning sugar. On the day of treatment the patient is  recommended to take commonly used antidiabetic drugs. All dental manipulation are to be done in the morning in1-2 hoursaftermealandinsulineinjection. Dentist needs to know the pecularities of this group of patients (thoroughchoice of tranquilizers for sedation, a good psychological climate at the reception, etc.).For local anesthetic Use drugs without epinephrine or those containing a vasoconstrictor substance, noradrenaline or felipressin. Duringthepostpostoperative prescribe means of chemotherapy to prevent infection, which in turn can cause glucosuria and lead to the development of coma. For patients with decompensated diabetics urgent dental intervention are held only in hospital.

12. Thyrotoxicosis.Thepatientswiththispathologyareextremelysensitivetostressandpain.As a resulteven tooth removal may cause a worsening thyrotoxicosis with the development of thyroid crisis, coma with complete loss of consciousness. Becauseof thyrotoxicosis dysfunction of other endocrine glands is possible, First of all it is adrenocortical function. This can lead to hypocorticism  and patient's death even with dental intervention.Prevention.Together with the endocrinologist before dental treatment cut off or significantly weaken thyrotoxicosis using medications do drug preparation with sedatives (aminazin 5% - 1 ml intramuscularly or sybazon 0.005 2 times a day inside). Suchpatientsaresensitivetoadrenalin, that’s why it should ne excluded from anesthetic solutions.

13. Hypothyroidism.Patientstendtohavecomplications(colds, secondary infections during surgical intervention). Asaresultofthefactthatduringhypothyroidism the function of other endocrine glands gets disrupted (especially adrenal), inadequate reaction to dental intervention is possibleand cab even lead to death. Prevention. Mandatory consultation with endocrinologist. in case of  affected forms of hypothyroidism dental intervention should be done in hospital together with complex treatment of this decease. Multiple tooth removing is not recommended.

A list of drugs needed for emergency aid at the dentists room

For rendering an effective medical assistance at the dentists room it is necessary

to have a set of medications. Here is the list represented by nosological forms.

 

PATIENT’S STATE

MEDICATIONS

1.

 

HEART STROKE

Validola; nitroglycerin tablets under the tongue or in sprays or one of its prolonged analogues (sustak, nitrosorbit, trinitrolong); Korvalol or valokordin; sybazon (seduksen, relanium, Diazepam) baralhin or tramal.

2.

INFARCTION:

nitroglycerin (nytrosorbyt, nitroglycerin in aerosol); promedol (tramal) sybazon (seduksen, relanium) suprastin (dimedrol, diprazin, tavehil) 0,1% solution of atropine sulfate.

3.

HYPERTENSIVE CRISIS:

Klofelin, dibazol, papaverine Hydrochloride; sibazon (relanyum, seduksen) baralgin; magnesium sulfate.

4.

PAROXYSMAL TACHYCARDIA STROKE

novokayinamid solution or 10% lidocaine solution. In case of syndrome Morhany-Adams-Stokes: 0,1% solution, atropine sulfate, 0,1% solution of adrenaline Hydrochloride, 5% solution of ephedrine Hydrochloride.

    5.

FAINTING:

ammonia: 10% solution kofeyn-sodium benzoate, kordiaminu solution, 0,1% solution of atropine sulfate.

6.

COLLAPSE:

Mesaton 1% solution, 5% solution of ephedrine, kordiaminu solution, 10% solution of caffeine-benzoate sodium, prednisolone or deksazon.

7.

MEDICINAL ANAPHYLACTIC SHOCK:

0,1% solution of adrenaline Hydrochloride, 0,1% solution of norepinephrine Hydrochloride, 2,4% eufilin solution, polyglukin, reopolyglukin, isotonic sodium chloride solution, 5% glucose solution;aerosol alupenta 1,5%, 0,1% solution of atropine sulfate, 2% solution of suprastin, 0,1% solution of tavehil, prednisolone (deksazon, dexamethasone); baralgin (tramal) sibazon (seduksen, relaium, diazepam), furosemide, 0,06% korglikon solution.

8.

ASTHMA:

aerosol bronchial spasmolytic (ventolyn or Berotec or alupent) pills mixture isoproterenol (0,005) and ephedrine hydrochloride (0.025) solutions - eufillin 2,4%, prednisolone (or deksazon) tavehil 0,1% (or suprastyn 2%) of atropine sulfate 0,1% (0,1% or metatsyna), adrenaline hydrochloride 0,1%.

9

ACUTE URTICARIA:

solutions: suprastin 2% (tavegil 0,1%), prednisolone (or deksazon) Adrenalin Hydrochloride 0.1% Ephedrine Hydrochloride 5% calcium gluconate 10%.

10.

ANGIONEUROTIC EDEMA:

solutions: suprastyn 2% (or tavehil 0,1%), prednisolone (or dexamethasone), adrenaline hydrochloride 0.1% (or noradrenaline hidrotartrata 0.2% Ephedrine Hydrochloride 5% mezaton 1%); uregid (etakrynovoyi acid) or furosemide (laziks).

11.

EPILEPSY SEIZURE:

sibazon (or seduksen, relanium, diazepam) 0,5% solution, aminazin 2,5% solution.

12.

HYSTERIA STROKE

hlozepida (chlordiazepoxide, elenium) sibazon (Diazepam, relanium, seduksen).

13.

THYROID CRISIS

solution of chlorpromazine, 0,5% solution sibazona (diazepam, relaniuma, seduksena), prednisolone, Inderal.

14.

DIABETES:

insulin, solutions: 40% glucose, caffeine, sodium benzoate 10%, kordiamin, mezatona 1% epinephrine hydrochloride 0,1%, 0,06% Korglikon or strophanthin 0,025%.

15.

REANIMATION

Solutions - epinephrine hydrochloride 0.1% or norepinephrine hydrotartratis, calcium chloride 10% sodium bicarbonate 4%, lidocaine 2% sodium chloride isotonic solution, polyglukin, reopoliglukin.

16.

BLEEDING

ditsinon 12,5%; Pambou (amben) 1% calcium chloride 10% ascorbic acid 5% Vitamin K - vikasol 1%; epsilon - aminocaproic acid, 5%, Vitamin P - rutin 0,05; dibazol 0,5% ; papaverine 2%; kaprofer; hemostatic or gelatin sponge "Krovostan" or oksitselodeks

 

6.1. TASKS FOR INITIAL KNOWLEDGE TESTING

1.          Causes of emergency conditions..

2.          What nust be ascertainedwith the patient before dental intervention?

3.          What are the methods of stress prevention?

4.          What is the special structure of the maxillofacial area?

5.          List the drugs that are used for premedication

6.          Name the medications that eliminate symptoms of deterioration of the cardiovascular system.

 

6.3 TENTATIVE FORM FOR STUDENT’S LITERATURE  SELF-LEARNING:

List of questions

Instructions to complete the task

Short answers

1. emergency state

List the pecularities of states that are associated with cardiovascular system, respiratory, endocrine system

 

2. medical assistance rendering

Describe the ways of rendering medical assistance

 

3. resuscitation.

Specify the methods of resuscitation.

 

 

7.1. Questionsforself-testingof learned material:

1.      What’s the doctor’s tactics during dizziness, collapse?

2.      Doctor's actions against hypertension or hypotension crisis

3.      General rules of premedication.

4.      The patient has a disease of diabetes.What are the precautions for preventing complications?

5.      Prevention of allergic reactions to impression materials (Bronchial asthma, angioneurotic edema)

7.2. Tasks for self-testing:

1.A43 y.o. patient turned to the clinic of prosthodontics in order to get prostheses. In the medical history there is a record about suffering from diabetes for 15 years. Before treatment he was very nervous. Suddenly his state got worse, he felt weakness in limbs. Patients got covered with cold sticky sweat and lost consciousness. What is the emergency state?

A      *Hypoglycemic coma

B      Faintning

C      Hyperglycemic coma 

D      Anaphylactic shock

 E     Myocardial infarction 

2.Whilemakinganimprintoftheupperjawforcreatinga restoring crown, a 30 y.o. patient had sudden excitation, acceleration and deepening of breathing, acceleration of pulse rate, increased BP. Cyanosis, sweating. What’s the most likely diagnosis in this case?

A      Asphyxia

B      Faintning

C      Collapse

D      Hypertensive crisis

E      Myocardial infarction

3. While waiting in a queue in front of the orthopaedist room a 64 y.o. patient fell down hoarsely breathing, convulsive twitching of hands and feet.The face and neck turned cyan, pupils are expanded, there is no reaction to light, blood pressure and pulse are not determined, heartbeating is not heardable, involuntary urination. What kind of state is characterized with these symptoms? 

A      *Clinical death

B      Loss of consciousness

C      Stroke

D      Myocardial infarction 

E      Collapse

4. A20 y.o. man got hit in the area of chin. He didn’t lose consciousness, the general condition is satisfactory. Aftertheexamination: thereisaedema and hematoma in the lower jaw from the both sides. Jaw is sharply painful on palpation. Mouth opening is limited. Tear of oral mucosa in the areas of 44, 43 and 34, 35 teeth. The bite is disturbed. What type of asphyxia may develop?

A      Dislocational

B      Obstructive

C      Stenotic

D      Valvular  

E      Aspirational   

5.While preparing teeth for artificial crowns a patient had an epileptic seizure. Define the doctor’s tactics in such a situation

A      *Lay the patient, put his head on one side, fix the tongue

B      No measures should be taken

C      Sit into an armchair vertically

D      Sit the patient, put his head forward, fix theback of the head

E      Lay the patient on his abdomen, fix his hands, put the head down  

 

6.      8. Literature for the teacher.

basic

Krishtab S.E. Prosthetic dentistry. К.: Vishya shkola,1986.–44Оp..

NespryadkoV.P., Rozhko М.М. Prosthetic dentistry. Kiev, Kniga plus, 2003.

Phantomcourseofprostheticdentistry./ underedit. V.N.Trezubov. – М. Меd. book. – 2003. – 341 p. –

Prosthetic dentistry. Applied materials. / V.N.Trezubov, M.Z. Shteingart, L.М.Mishnev- S.-Petersburg, 1999. -  324 p

.

Zhulev E.N. Material Science in Prosthetic Dentistry. . - M., 1998  .

Kashirin V.N. Dental technician. Dental Materials. - M., 1973

Dental prosthetic equipment. /L.D. Chulak,V.G. Shuturminskiy– Odessa, 2001 г. - 315 p

additional

Arzhantsev P.Z. Treatment of facial injuries .- M.: Medicine, 1975.

Vadalyan H.A. Treatment of fractures of the jaw and facial bones. Textbook.1984

Vares E.A., Knotko G.P. Replacement prostheses of the upper jaw.-K., 1981

Napadov A.L. Articulation and prosthetic dentistry .- K.: Health, 1984

Occlusion and clinical practice / ed. I. Klineberg, R. Jager, Ed. from English. under gen.red. M. Antonik. - M.: MEDpress-inform, 2006. - 200C

 

8.1.Literature for Students

Basic educational

Kopeikin V.N. Dental appliances. - M. Medicine, 1998.

Prosthetic Dentistry / Gavrilov E.N., Scherbakov A.S., Zhulev E.N. / Moscow, 1998. - 345.

Kabanov B.Y, Lukyanenko V.I., Arzhantsev P.Z. "Short course of a military Dentistry". L, Medicina, 1973, p.. 208-209.

Varava G.M., Strelkovsky K.M. Techniques Maxillofacial prostheses.-K., 1992 p. 140.

Nespryadko V.P., Rozhkov M.M. Prosthetic Dentistry. Kyiv, Knyha plus, 2003.

Krishtab S.E. Prosthetic dentistry. К.: Vishya shkola,1986.–44Оp

additional (Scientific, methodical)

Napadov M.A., Sapozhnikov A.L., Gerner, M.M. Materials for prosthetic dentistry. - K., 1979.

 

9. Task for educative research student’s work and scientific research student’s work on present topic. Prepareareportabouremergencystatesthatmayoccurduringdentalinterventions.

10. Thefollowingworkshoptop.Posttraumaticcomplicationsoflowerjawfracture.

 

Recommendations were made by________________as. / Kovalchuk L.P. /