Post operative emergency management in periodontics


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  • Post operative emergency management in periodontics

    2. 2. <ul><li>The most significant complication or emergency occur in PERIODONTAL THERAPY are </li></ul><ul><li>1. SHOCK, SYNCOPE </li></ul><ul><li>2. HEMORRHAGE </li></ul><ul><li>3. PAIN </li></ul><ul><li>4. SWELLING, HEMATOMA </li></ul><ul><li>5. DELAYED HEALING </li></ul><ul><li>6. ALLERGIC REACTIONS TO DRESSING </li></ul><ul><li>7. SENSITIVITY OF THE TEETH </li></ul><ul><li>SHOCK :- </li></ul><ul><li>- The most serious of all complication is anaphylactic shock to an administride drug. </li></ul><ul><li>- it is life threatening state, which require immediate attention. </li></ul>
    3. 3. CLINICAL MANIFESTATIONS:- <ul><li>- It usually develops with in about one half hour following administration of drug. </li></ul><ul><li>- The patient feels uneasy, difficulty in breathing, nausea, becomes pall, then cynotic, perspiry heavily and collapse. </li></ul><ul><li>- The blood pressure becomes very low and the pulse flast and weak or it may be felt at all. Respiration becomes asthmatic. </li></ul>
    4. 4. MANAGEMENT:- <ul><li>- The assistant should be introduced to call emergency service whenever it is suspected that the patient is going into shock. </li></ul><ul><li>- Place the patient in trendelen burg´s position, clear the air passages and administer oxygen. </li></ul><ul><li>- If the blood pressure is very low, give 0.5 ml. epinephrine (1:1000 injectable form) intramuscularly, preferably in the tongue muscles. </li></ul><ul><li>- It may be given in any large muscle. </li></ul>
    5. 5. <ul><li>- Do not inject epinephrine subcutaneouly, that may, it is absorbed very slowly. </li></ul><ul><li>- If the patient`s heart has stopped completely, emergency external heart massage should be introduced, if the breathing has also stopped, artificial respiration should be given until emergency help arrives. </li></ul><ul><li>- All the personnel in the dental office should recive training periodically in cardiopulmonary resuscitation (CPR) produces so that they can assume an active role in an emergency situation. </li></ul>
    6. 6. <ul><li>If the patient shows signs of agitation and chest pain, oxygen should be administered and the emergency service called, since these symptoms may indicate a heart attack. Administration of epinephrine would be contraindicated for such patient. </li></ul>
    7. 7. OTHER CAUSES <ul><li>- Of shock like symptoms may be hypoglycemia of insuline shock in diabetes. </li></ul><ul><li>Individual with hypoglycemia may require a suger containing beverage prior to and during periodontal surgery. </li></ul><ul><li>Shock may also be the result of loss of blood. Internal hemorrhage or cardiovascular accidents. The most important action in any shock like reaction are called in emergency help immediately and to adminiter supportive emergency therapy. </li></ul>
    8. 8. SYNCOPE:- <ul><li>- The most common cause of loss of consciousness in the dental chair is simple syncope. </li></ul><ul><li>- The situation is unpleasant and embrassing to the patient and disruptive to the treatment procedures. </li></ul>
    9. 9. MANAGEMENT :- <ul><li>If the patient starts to become abnormally pale perspire heavily and is restless, place the chair in horizontal position with the head below the level of the body. </li></ul><ul><li>If the pulse become noticeable weaker than normal, record the blood pressure. </li></ul><ul><li>Aromatic ammonia may help to prevent syncope. </li></ul><ul><li>If the patient is in deep syncope and making slow recovery, oxygen should be administered. </li></ul><ul><li>While the patient is regaining consciousness, he should be kept in horizontal position and should not be allowed to sit up until his normal color has returned and is fully recovered from a feeling of dizziness and nausea. </li></ul>
    10. 10. PRECAUTION :- <ul><li>- The patient fears through psychological and pharmacological preparation before the surgery. </li></ul><ul><li>- Instruments and blood should be kept outside the patient`s field of vision. </li></ul>
    11. 11. HEMORRHAGE:- <ul><li>Because periodontal surgery ordinarily reverse only small blood vessels, significant hemorrhage is not a frequent complication of periodontal surgery when local anesthetics and vasoconstrictor drugs are used. </li></ul><ul><li>Average amount of blood loss during one session of periodontal surgery has been reported to be 37ml. </li></ul><ul><li>Periodontal surgery has usually been ruled out during the treatment planning for the patient while bleeding disorders. </li></ul>
    12. 12. CAUSES:- <ul><li>Bleeding disorders for instance. </li></ul><ul><li>Heavy intake of aspirin or the other drugs after the systemic and hygienic phase of treatment. </li></ul><ul><li>Abnormal bleeding may be related to unexpected on set of menstrual period. </li></ul><ul><li>There may also be accidental severing of large blood vessels during surgery ,provoking extensive bleeding. </li></ul>
    13. 13. Hemorrhage Primary Intermediate Secondary
    14. 14. PRIMARY:- <ul><li>Primary postoperative hemorrhage starts at the time of surgery. </li></ul>
    15. 15. INTERMEDIATE:- <ul><li>- Intermediate hemorrhage starts soon after the surgery, after having stopped temporarily following surgery. </li></ul><ul><li>It is due to break down of incomplete clot, such as associated with loss of vasoconstrictor effect of anesthesia. </li></ul>
    16. 16. SECONDARY:- <ul><li>- The secondary type post surgical hemorrhage may starts from 24 hours to 10 days postoperatively. The patient should be instructed to contact the dentist, who did the surgery immediately if intermediate or secondary hemorrhage occurs. </li></ul>
    17. 17. MANAGEMENT <ul><li>First to reassure the Patient and control the patient’s emotional concern about the bleeding . </li></ul><ul><li>A mild oozing type of bleeding can usually be controlled by a pressure pack , using gauze moistened in sterile saline solution and held firmly in position for 2-3 minutes . Injection of LA along with 1:50,000 vasoconstrictor drug may also be helpful in controlling bleeding </li></ul>
    18. 18. <ul><li>If the bleeding is arterial spouting of light red blood as may be seen with encroachment on the palatal anterior , one may try to crush the cut artery with a hemostat. Hold the hemostat in position for several minutes and remove it carefully . If there is not enough soft tissue to grasp the hemostat one may attempt to seal the vessel by crushing the bone of nutrient bone channel . If the cut are surface is in soft tissue, cautery may be tried either by a hot instrument or a ball electrode from an electrosurgical machine. </li></ul>
    19. 19. <ul><li>If the bleeding is severe, it may have to be stopped by tying a suture around the bleeding vessel. </li></ul><ul><li>A slow , oozing , venous bleeding (dark blood) may be stopped by the use of Gelfom or oxygel. </li></ul><ul><li>These preparation are somewhat irritating and definitely have to be removed before a periodontal dressing is placed over the wound. </li></ul><ul><li>The placement of periodontal dressing helps to stop bleeding , and there is no need to have an absolutely dry surgical field with complete stoppage of all bleeding , prior to the placement of dressing. </li></ul>
    20. 20. <ul><li>The patient should never be allowed to leave the dentist office until all gross hemorrhaging has stopped. </li></ul><ul><li>If intermediate or secondary hemorrhage occurs , administration of local anesthetic with vasoconstrictor centrally to the wound is recommended . The remove periodontal dressing, clean and inspect the wound and treat the bleeding similarly to a primary type of bleeding . </li></ul>
    21. 21. PAIN <ul><li>During the first 24 hours following the periodontal surgery , there should be only minimal pain and discomfort if the basic principles of atraumatic surgery were absorbed carefully. </li></ul><ul><li>CAUSES </li></ul><ul><li>Mechanical trauma during surgery. </li></ul><ul><li>Drying the bone </li></ul><ul><li>Traumatic bone surgery or incorrectly placed periodontal dressing </li></ul><ul><li>A very common source of post operative pain is impingement from the post surgical dressing . </li></ul>
    22. 22. <ul><ul><li>Management </li></ul></ul><ul><ul><li>The surgical area should be anesthetized , the dressing removed and the cause of pain is identified . </li></ul></ul><ul><ul><li>When the cause has been eliminated a new carefully fitted dressing should be placed in to the position. </li></ul></ul><ul><ul><li>The dressing that is placed inter proximally should be soft , so that it can cover the wound without pressure </li></ul></ul><ul><ul><li>After the dressing has been changed the patient may be given pain relieving medication, however medication usually for few days </li></ul></ul>
    23. 23. <ul><li>INFECTION </li></ul><ul><li>Usually does not start until 2-4 days following surgery. </li></ul><ul><li>Such pain is usually accompanied by lymphadenopathy and there may be slight elevation in temperature </li></ul><ul><li>If do not treated promptly , the lymph adenopathy and the elevation in temperature will increase </li></ul><ul><li>The patient should be examined, the temperature recorded and the periodontal dressing removed . </li></ul><ul><li>If the temperature is no significantly elevated and the teeth are not noticeable sour to percussion , place a topical antibiotic ointment (eg. 3% achromycin) over the wound and apply a new dressing . </li></ul><ul><li>The patient should be introduced to take his temperature is significantly elevated or the teeth in the area of the surgery are noticeably sour to percussion . </li></ul>
    24. 24. <ul><li>The patient should be placed on systemic antibiotic therapy. Fever and soreness of the teeth to percussion may indicate a developing osteomyelitis and the patient should be treated with large doses of antibiotics, preferably PENICILLIN . </li></ul><ul><li>Doubling the normal dosage for atleast 10- 14 days is recommended for osteomyelitis .s </li></ul>
    25. 25. Periodontal surgery Periodontal surgery Exposure of part of alveolar process. Severe trauma to the bone or heavy direct pressure on the bone from the periodontal dressing Development of bare bone Resorption of necrotic bone by inflammatory process. Sequestrem formation
    26. 26. <ul><li>During this time the area should be kept covered by a periodontal dressing to minimize the infection and discomfort. </li></ul><ul><li>The chance of bare bone developing is much greater following gingivectomy with electrosurgery . If excessive granulation tissue develops as a result of poorly fitting periodontal dressing or loss of the dressing shortly after surgery , the granulation tissue should removed with sharp instrument . A well fitting periodontal dressing then should be placed over the wound and left for one week. </li></ul>
    27. 27. REACTION TO PERIODONTAL DRESSING <ul><li>Allergic reaction to periodontal dressing some times occur especially in patient who have been wearing dressing over a prolonged period of time due to multiple epixodes of surgery or delayed healing. </li></ul><ul><li>The sensitivity reaction is usually provobed by the eugenol in zinc oxide eugenol type of dressing. </li></ul><ul><li>It has been observed , although very rarely with noneugenol containing dressing. </li></ul><ul><li>First symptom of a sensitivity reaction to periodontal dressing is a burning sensation in the buccal mucosa and on the surface of the tongue where contact with dressing occur. </li></ul>
    28. 28. <ul><li>The patient should be told at time of the surgery of the possibility of such symptom occurring and instructed to contact the dentist on experiencing them. </li></ul><ul><li>If the dressing is not removed , the reactionm progress from erythema to vesicle formation and edema ( which is especially in relation to the tongue ) may be serious complication, since epiglottal edema interfere with air passage. </li></ul><ul><li>If the patient is not treated a generalized allergic reaction may develop , including a dermatitis and the patient may become seriously ill . </li></ul><ul><li>It is therefore very important that the surgical dressing be removed completely as soon as any of the initial symptoms of allergic reaction appear . </li></ul><ul><li>If a new dressing is needed a non eugenol- containing type of dressing, such as coe-pack or peripak may be used . </li></ul>
    29. 29. <ul><li>The patient should also be given systemic antihistamines for at least 4-5 days inorder to intercept the allergic reaction. </li></ul><ul><li>With severe allergic reaction, the patient may have to be hospitalized and given cortison therapy . </li></ul><ul><li>Type of treatment should be the responsibility of a qualified physician rather than of dentist . </li></ul>
    30. 30. SENSITIVITY OF THE TEETH <ul><li>The root surface of the teeth that have been exposed to the oral environment as a result of periodontal surgery sometimes become extremely sensitive to heat and cold , as well as to mechanical and chemical stimuli. </li></ul>
    31. 31. MANAGEMENT <ul><li>Optimal post surgical plaque control this sensitivity usually abates over a few weeks or month occasionally it may resist over aq long period of time . </li></ul><ul><li>A large number of procedure and medicaments have been recommended for treating such sensitivity , however none is spectacularly effective . </li></ul>
    32. 32. <ul><li>Tooth paste for reduction of sensitivity provide varying degrees of relief for long term sensitivity . </li></ul><ul><li>Topical fluoride application are often used . </li></ul><ul><li>Combining fluorides and electrical has been claimed to reduce sensitivity , but the reduction apparently is not dependent on the use of electric current. </li></ul>
    33. 33. <ul><li>Iortophoretic devices and denifries for root hypersensitivity should be prescribed as possible means of reducing discomfort. </li></ul><ul><li>Vigorous plaque control in the most significant factor in long term reduction of sensitivity , unless the sensitivity is related to occlusal dysfunction , which requires the oral therapy. </li></ul>