RU2070030C1 - Method of treatment of maxillofacial region inflammatory disease in patients with diabetes mellitus - Google Patents

Abstract

FIELD: medicine, surgery stomatology. SUBSTANCE: method involves complex treatment of patient with diabetes mellitus and acute suppurative-inflammatory disease of maxillofacial region involving surgery operations and insulin administration. Beginning from 3-6 day after surgery operation the wound is treated with 3.5% olifen solution for 6-8 days. To patients with severe diabetes mellitus course and spacious suppurative-inflammatory processes olifen tablets were given simultaneously (0.5 g, 3 times per a day for 7-10 days). EFFECT: decreased treatment period, accelerated regeneration, enhanced effectiveness.

Description

 The method relates to medicine, namely to surgical dentistry.

There are various methods of treating inflammatory processes of the soft tissues of the neck, face and jaws. The basic treatment regimen for acute odontogenic infection consists of a set of measures. Its main components are:
1. Surgery to drain the intraosseous focus of inflammation and purulent focus in the soft tissues.

 2. Antimicrobial treatment.

 3. Detoxification treatment.

 4. Desensitizing treatment.

 5. Measures to restore homeostasis of the main functional systems of the body.

 6. General strengthening and stimulating treatment in order to increase the immunobiological properties of the tissues of the face and the body as a whole (Gruzdev N.A. Acute odontogenic infection. M. Medicine, 1978. P.77).

 One of the pressing issues of modern purulent surgery is the treatment of inflammatory diseases that develop and / or occur in patients with diabetes mellitus. Surgical infection and diabetes mellitus, proceeding simultaneously, differ in a number of features. On the one hand, any, even insignificant, purulent focus causes a violation of all metabolic processes, leads to insulin deficiency, the progression of diabetes mellitus and its decompensation. On the other hand, metabolic disorders, slowing down the regeneration and repair of tissues, complicate and aggravate the course of the inflammatory process.

 It is known that disorders of carbohydrate, protein and fat metabolism, shifts in electrolyte, water balance, activation of lipid peroxidation (LP), suppression of the regenerative and reparative abilities of the body are inevitable companions of diabetes. It is believed that tissue hypoxia is one of the pathogenetic factors of complex metabolic changes in diabetes mellitus. Violation of the LPO course (increase in the intensity of initiating effects, depletion of antioxidant reserves, development of peroxidation syndrome) causes damage to the structural and functional organization of membranes, suppression of the functioning of mitochondria, accumulation of biologically inert polymers. In patients with diabetes mellitus, regardless of age, there is a significant decrease in sulfhydryl groups, which are an active group of many biologically active substances in the body involved in metabolic processes that determine the synthesis and accumulation of acid mucopolysaccharides, collagen formation. In diabetes, there is a protein deficiency, intrinsic deficiency of sulfhydryl groups, which, in all likelihood, causes the disorder of the mucopolysaccharide complex (Pogozheva E.E. Amiraslanov Yu.A. Morenkova S.A. Purulent infection and diabetes mellitus: a scientific review. M. 1980. 56 s.).

Comprehensive treatment of purulent diseases in diabetes should be carried out subject to the following conditions:
a) surgical intervention with a wide opening of the foci of destruction and subject to adequate drainage;
b) antibiotic therapy, the use of chemical antiseptics;
c) increasing the immunoreactivity of the body;
d) detoxification and desensitization therapy;
e) correction of violations of water-salt, electrolyte, carbohydrate, protein metabolism, acid-base conditions, nonspecific body protection (Struchkov V.I. Gostishchev V.K. Struchkov Yu.V. Guidelines for purulent surgery (USSR Academy of Medical Sciences. M. Medicine , 1911.p. 103-113).

The disadvantages of the traditionally used methods of therapy in the complex of therapeutic measures for inflammatory diseases in patients with diabetes mellitus are:
1. The need for a long stay of the patient in a hospital.

 2. The traditional method of treatment does not provide for the use of drugs that have a pronounced antioxidant and antioxidant effect, which does not eliminate hypoxia of the tissues of the purulent wound.

 3. The presence of a significant number of contraindications for the use of physiotherapeutic procedures (for example, electrophoresis of drugs, diadynamic therapy), acute phase of tissue inflammation, individual intolerance to electric current, hypertension, malignant tumors of the maxillofacial region, erosive-ulcerative processes of the oral mucosa, etc. P.

 4. The possibility of developing an allergic reaction of an immediate and delayed type in response to the use of antibiotics, sulfonamides, antiseptics and other drugs in the medical complex.

 The closest way to treat purulent-inflammatory diseases in patients with diabetes mellitus is a complex one, which consists in the fact that under adequate anesthesia and corrective therapy aimed at maintaining and restoring the body's functions impaired by the disease, surgery is performed (opening and draining the abscess), correcting carbohydrate exchange with fractional use of insulin, the appointment of broad-spectrum antibiotics, detoxification and immunocorrective therapy (Molchanov and K.A. Karandashov V.I. // Dentistry. - 1981. N 1. P. 42-44; Huseynov R.R. // Dentistry. 1984. N 1. P. 48-50; Meser Ahmed // Dentistry. 1989. N 4. S. 41-44).

 A known method of topical application of ointment "Iruksol" and Shostakovsky balm in the treatment of purulent-inflammatory diseases of soft tissues in patients with diabetes mellitus. These drugs were used to accelerate the healing of wounds from necrotic tissues and stimulate regeneration. However, despite the improvement of treatment results, the average duration of inpatient (36 bed / days) and general (50-57 days) treatment remained quite large, fatal outcomes were observed (Goryunov A.I. Kuleshov E.V. // Sov. Medicine. - 1987. N 4. C.117-119). In addition, the method used by the authors did not eliminate hypoxia.

Therefore, the disadvantages of the traditionally used methods of treatment of purulent-inflammatory diseases of the maxillofacial region in patients with diabetes mellitus are:
1) low efficiency, manifested by delayed cleansing of the purulent wound from necrotic tissues, sluggish development of granulation as a result of metabolic disorders, microcirculation disorders and hypoxia;
2) multicomponent;
3) the duration of treatment;
4) a significant frequency of complications and high mortality (7-22%).

 The aim of the invention is to reduce the duration of treatment and increase its effectiveness.

 The essence of the invention lies in the fact that a patient with diabetes mellitus with acute purulent-inflammatory diseases of the maxillofacial region (periostitis of the jaw, osteomyelitis of the jaw, abscess, phlegmon) undergoes complex treatment, including opening and draining the abscess, antibacterial and detoxification therapy (administration of insulin blood glucose by insulin). In addition, after surgery (from 3-6 days), local therapy is carried out for 3-5 days with 3.5% aqueous solution of olifene and / or oral administration of the latter 0.5 g 3 times a day for 7-10 days . Oliphene, due to its high electron-acceptor properties due to the polyphenolic structure, has a direct effect on the respiratory chain of mitochondria. The presence of a thiosulfate group in the polymer structure of the preparation determines its pronounced antiradical and antioxidant effect. This helps to improve the processes of respiration in the tissues, the normalization of impaired metabolic processes in the body, which leads to an acceleration of the process of regeneration of wounds, bringing it closer to natural conditions. The choice of dosage and course of treatment is based on instructions for the use of olifene (decision of the Pharmacological Committee of the Ministry of Health of the USSR N 01 of 03/18/08).

 The method is as follows: from 3-6 days after surgery (opening and draining the abscess), the wound is treated with antiseptic solutions (0.05% chlorhexidine bigluconate, 1: 5000 furatsilina), followed by irrigation with physiological saline, and then washing with 3.5 % solution of oliphene. Over the next 6-8 days, the wound was loosely swabbed with turunda moistened with the same solution for a day. Topical application of a 3.5% solution of oliphene continues until abundant granulations and wound epithelialization appear, and secondary sutures are applied. Patients with diffuse inflammatory processes and decompensated diabetes mellitus of moderate severity are given 0.5 g three times a day 30 minutes before meals with topical administration of the drug olifenum for 7-10 days. In the case of severe diabetes mellitus and a limited inflammatory process, olifene is administered orally in the same doses for 7-10 days.

зубе. За медицинской помощью не обращался. Общее состояние при поступлении тяжелое: больной бледен, адинамичен, температура тела 38,1 ^o С, артериальное давление 110/80 мм рт.ст. пульс 92 в 1 мин, удовлетворительных качеств, частота дыхания 20 в мин. Местно: асимметрия лица за счет инфильтрата и выраженного отека мягких тканей подбородочной, околоушно-жевательной, поднижнечелюстной областей справа. Инфильтрат без четких границ, резко болезненный при пальпации. АВ поднижнечелюстной области справа определяется флюктуация. Открывание рта болезненно, до 0,5 см. Коронка

разрушена наполовину, перкуссия его болезненна. Слизистая оболочка в области крыловидно-челюстной складки инфильтрована и гиперемирована. Анализ крови при поступлении: СОЭ 52 мм в час, эр. 3,59 • 10¹²/л, ц.п. 0,94, гемоглобин 110 г/л, лейкоциты 11,2 • 10⁹/л, ЛИИ 4,1, ПСМ 0,41 ед. Сахар крови - 15:5 ммоль/л. В моче: белок 1,65% уд. вес 1043, лейкоциты в большом количестве, эритроциты до 15-18 в поле зрения, единичные гиалиновые и зернистые цилиндры. Выявлено возрастание интенсивности ПОЛ: концентрация МДА достигла 12,4 ммоль/л, ПРЭ до 5,5%
Учитывая тяжесть состояния, больной был переведен в реанимационное отделение, где ему была проведена коррекция гликемии и осуществлена предоперационная подготовка. После снижения концентрации сахара в крови (до 6,7 ммоль/л) и проведения предоперационной дезинтоксикационной терапии под общим обезболиванием произведено вскрытие флегмон. В последующем больному проводилась дензинтоксикационная, антибактериальная и дегидратационная терапия, коррекция гликемии, обработка гнойной раны. После перевода больного в стоматологическое отделение (на 7 сутки) в комплексное лечении был включен олифен (перорально по 0,5 г три раза в сутки в течение 10 дней). При перевязках после проведения некротомии, промывания раны растворами антисептиков (фурацилина, хлоргексидина), промывания раны растворами антисептиков (фурацилина, хлоргексидина), а затем физиологическим раствором из шприца с канюлей проводилась ирригация ее 3,5% раствором олифена. В рану рыхло в течение 6 суток вводилась турунда, пропитанная этим же препаратом. Уже на вторые сутки после комбинированного применения олифена больной отметил улучшение общего состояния: стал более активным, прекратилось гноетечение из раны, на 3 сутки появились обильные розовые грануляции, выраженная краевая эпителизация. Это позволило на 6 сутки наложить вторичные швы на рану. Проведя в стационаре 24 койкодня, больной в удовлетворительном состоянии 21.09.92 г. выписан на амбулаторное лечение. Перед выпиской нормализовались показатели гомеостаза: количество эр-тов увеличилось до 4,43 • 10¹²/л, содержание гемоглобина до 130 г/л, число лейкоцитов уменьшилось до 8,0 • 10⁹/л, СОЭ достигла 26 мм в час, ЛИИ снизился до 1,3. Нормализовались и показатели ПОЛ.PRI me R 1. Patient B-s A.N. 29 years old, was admitted to the dental department of the Smolensk region of a clinical hospital on September 3, 1992 with a diagnosis of phlegmon of the submandibular, masticatory, pterygo-maxillary and periglottic spaces on the right: diabetes mellitus (type I, moderate). Complaints on admission to general weakness, chills, pain, swelling in the submandibular and parotid-chewing areas on the right, painful swallowing. Sick 6 days when there was pain in

a tooth. I did not seek medical help. The general condition at admission is severe: the patient is pale, dynamic, body temperature 38.1 ^o C, blood pressure 110/80 mm Hg pulse 92 in 1 min, satisfactory qualities, respiratory rate of 20 per min. Locally: asymmetry of the face due to infiltration and severe swelling of the soft tissues of the chin, parotid chewing, submandibular regions on the right. Infiltrate without clear boundaries, sharply painful on palpation. AV submandibular region on the right is determined by fluctuation. Opening the mouth is painful, up to 0.5 cm. Crown

half destroyed, its percussion painful. The mucous membrane in the region of the pterygo-maxillary fold is infiltrated and hyperemic. Blood test at admission: ESR 52 mm per hour, er. 3,59 • 10 ¹² / l, c.p. 0.94, hemoglobin 110 g / l, white blood cells 11.2 • 10 ⁹ / l, LII 4.1, PSM 0.41 units. Blood sugar - 15: 5 mmol / L. In urine: protein 1.65% beats. weight 1043, white blood cells in large numbers, red blood cells up to 15-18 in the field of view, single hyaline and granular cylinders. An increase in the LPO intensity was revealed: the concentration of MDA reached 12.4 mmol / L, the REM to 5.5%
Given the severity of the condition, the patient was transferred to the intensive care unit, where he underwent glycemic correction and preoperative preparation. After lowering the concentration of sugar in the blood (up to 6.7 mmol / L) and conducting preoperative detoxification therapy under general anesthesia, phlegmon was opened. In a subsequent patient, denzintoxication, antibacterial and dehydration therapy, glycemia correction, and treatment of a purulent wound were performed. After the patient was transferred to the dental department (on the 7th day), olifene was included in the complex treatment (0.5 g orally three times a day for 10 days). During dressings after necrotomy, washing the wound with solutions of antiseptics (furatsilina, chlorhexidine), washing the wound with solutions of antiseptics (furatsilina, chlorhexidine), and then saline with a 3.5% solution of oliphene was carried out from the syringe with cannula. Turunda impregnated with the same preparation was loosened within 6 days. Already on the second day after the combined use of olifen, the patient noted an improvement in general condition: he became more active, suppuration from the wound stopped, profuse pink granulations appeared on the 3rd day, pronounced marginal epithelization. This allowed for 6 days to impose secondary sutures on the wound. After spending 24 beds in a hospital, the patient in satisfactory condition was discharged to outpatient treatment on September 21, 1992. Before discharge, homeostasis indicators returned to normal: the number of erts increased to 4.43 • 10 ¹² / l, the hemoglobin content to 130 g / l, the number of leukocytes decreased to 8.0 • 10 ⁹ / l, ESR reached 26 mm per hour, LII dropped to 1.3. LPO indicators also returned to normal.

зубе. Общее состояние при поступлении средней тяжести. Местно: асимметрия лица за счет отека и умеренной инфильтрации околочелюстных мягких тканей справа, утолщение тела нижней челюсти. Пальпация его болезненна. Симптом Венсана положительный. Кожа околочелюстной области в цвете не изменена, свободно собирается в складку. Открывание рта ограничено до 1,5 см. Со стороны полости рта: коронка

зуба разрушена наполовину, перкуссия его слабо болезненна. Переходная складка справа отечна и инфильтрирована, выбухает. Имеется отек слизистой оболочки ретромолярной области и крыловидночелюстной складки справа. Лечение: под общим обезболиванием произведено удаление

зуба, сделан разрез слизистой оболочки по переходной складке, получен гной, рана дренирована. Назначены: канамицин по 0,5 три раза в день в/мышечно, 10% раствор хлорида кальция по 1 столовой ложке три раза в день. Проводились: полоскания полости рта растворами антисептиков, ежедневные ирригации раны растворами фурацилина, хлоргексидина биглюконата, полуспиртовые и мазевые компрессы на область тела нижней челюсти справа. Консультантами эндокринологом и терапевтом рекомендованы инъекции инсулина по схеме, сердечные гликозиды. Со второго дня после оперативного вмешательства больной назначен олифен внутрь по 0,5 г три раза в день в течение 7 дней. На 3 сутки после начала приема олифена отмечено интенсивное разрастание розовых грануляций в ране, выраженная краевая эпителизация, уменьшение отека и инфильтрации мягкий тканей. Нормализовалась температура тела, улучшилось состояние больной. Ко дню выписки 26.02.92 г. (на 10 сутки) рана полностью заэпителизировалась. В процессе лечения олифеном наблюдалось более значительное снижение эндогенной интоксикации (ЛИИ уменьшился с 3,4 до 2,1 ед. а концентрация среднемолекулярных пептидов СМП снизилась с 0,31 до 0,26 ед. ). Наблюдалась нормализация ПОЛ: содержание малонового диальдегида (МДА) снизилось с 7,9 до 7,0 ммоль/л, а перекисная резистентность эритроцитов (ПРЭ) с 3,5% до 3%
Указанный способ лечения гнойно-воспалительных заболеваний челюстно-лицевой области применен у 5 больных сахарным диабетом. Во всех случаях получены хорошие ближайшие и отдаленные (до 10 месяцев) результаты лечения. Все больные отмечали улучшение общего состояния, самочувствия. Отмечалось значительное снижение интоксикации, определяемое как клинически, так и с помощью лабораторных исследований. Нормализовались показатели перекисного окисления липидов. После двух-трехкратной обработки ран раствором олифена уменьшились боли в очаге поражения отек и инфильтрация мягких тканей, гноетечение; ускорялось очищение раны от некротизированных тканей. На 3-4 день появлялись обильные грануляции и краевая эпителизация.PRI me R 2. Patient Sh-va Z.Ya. 70 years old, was hospitalized on February 17, 1992 to the dental department of the hospital with a diagnosis of odontogenic osteomyelitis of the lower jaw on the right (acute phase), diabetes mellitus (type II, moderate). Complaints on admission to general weakness, painful swelling of the right cheek, limited opening of the mouth, pain when swallowing, numbness of the skin in the chin and lower lip on the right. Sick for about two weeks. The disease is associated with the appearance of pain in

a tooth. General condition upon receipt of moderate severity. Locally: asymmetry of the face due to edema and moderate infiltration of the maxillary soft tissues on the right, thickening of the body of the lower jaw. Palpation is painful. Vincent's symptom is positive. The skin of the maxillary region in color is not changed, it is freely collected in a fold. The opening of the mouth is limited to 1.5 cm. From the side of the oral cavity: crown

the tooth is half destroyed, its percussion is slightly painful. The transitional fold on the right is swollen and infiltrated, bulges out. There is swelling of the mucous membrane of the retromolar region and the pterygo-maxillary fold on the right. Treatment: removal under general anesthesia

of a tooth, an incision of the mucous membrane along the transitional fold was made, pus was obtained, the wound was drained. Appointed: kanamycin 0.5 three times a day / muscle, 10% solution of calcium chloride, 1 tablespoon three times a day. The following were carried out: rinsing the oral cavity with antiseptic solutions, daily wound irrigation with solutions of furatsilin, chlorhexidine bigluconate, half-alcohol and ointment compresses on the lower jaw body area on the right. The endocrinologist and therapist recommended the injection of insulin according to the scheme, cardiac glycosides. From the second day after surgery, the patient was prescribed olifen inside of 0.5 g three times a day for 7 days. On the 3rd day after the start of olifen administration, there was an intensive growth of pink granulations in the wound, pronounced edge epithelization, a decrease in edema and soft tissue infiltration. Normalized body temperature, the patient's condition improved. By the day of discharge on February 26, 1992 (on the 10th day), the wound was completely epithelized. During treatment with olifen, a more significant decrease in endogenous intoxication was observed (LII decreased from 3.4 to 2.1 units and the concentration of medium molecular weight peptides of SMP decreased from 0.31 to 0.26 units). LPO normalization was observed: the content of malondialdehyde (MDA) decreased from 7.9 to 7.0 mmol / L, and red blood cell peroxide resistance (RED) from 3.5% to 3%
The specified method for the treatment of purulent-inflammatory diseases of the maxillofacial region was used in 5 patients with diabetes mellitus. In all cases, good near and long-term (up to 10 months) treatment results were obtained. All patients noted improvement in general condition, well-being. There was a significant reduction in intoxication, determined both clinically and through laboratory studies. Normalized lipid peroxidation. After two or three times the treatment of wounds with a solution of oliphene, the pain in the lesion site decreased swelling and soft tissue infiltration, suppuration; accelerated wound cleansing from necrotic tissue. On day 3-4, abundant granulations and marginal epithelization appeared.

The proposed method for the treatment of inflammatory diseases of the maxillofacial region in patients with diabetes provides the following advantages:
1. It is an example of a highly effective pathogenetic treatment of these diseases in patients with diabetes mellitus, since oliphene in conditions of tissue hypoxia increases the effectiveness of tissue respiration.

 2. The use of olifen after the first procedures accelerates the hydration phase (reducing it from 6 to 3 days) and its transition to the phase of wound dehydration, reduces inflammation, cleanses the wound of necrotic tissue, accelerates wound healing (the appearance of granulation, epithelization), which most pronounced after local treatment of the wound with a solution of oliphene and ingestion of the latter by mouth.

 3. Reduces the total duration of treatment.

 4. Reduces by 4-5 days the timing of the secondary seams.

 5. The method is simple and can be implemented in the practice of dentists, clinics, medical units.

Claims (1)

 A method for the treatment of inflammatory diseases of the maxillofacial region in patients with diabetes mellitus by surgical intervention and drug therapy, characterized in that the patient is injected with an additional 3.5% aqueous solution of oliphene into the wound on turunda for 6-8 days to patients with severe sugar diabetes and diffuse purulent-inflammatory processes at the same time prescribe tablets of the specified drug at 0.5 g 3 times a day for 7 to 10 days.