RU2540517C1 - Method for performing dental interventions in patients suffering acute stroke - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: performing a dental intervention in the patients suffering an acute stroke requires the oral administration or injections of a broad-spectrum antibiotic after examining the mouth or determining the extent of the dental intervention extent 30-60 minutes before the expected intervention. The patient is placed in a dental chair in a reclining posture at an angle of 35-50 degrees; a blood pressure is measured, and if the measured systolic pressure is 135-145 mm Hg, the dental intervention is performed. The dental intervention involves blood pressure monitoring, while the conduction anaesthesia is performed with 3% mepivacaine in a combination with the infiltration anaesthesia with 4% articaine with epinephrine 1:200,000 in a quantitative ratio 3:1.

EFFECT: method enables reducing complications and minimising injuries of the dental interventions by using the smoothest possible technique thereof.

3 ex

Description

The invention relates to medicine, in particular to neurology and dentistry, and can be used for dental surgery in patients with an acute period of stroke.

Stroke is understood to mean cases of acute cerebrovascular insufficiency (stroke), in which symptoms of damage to the nervous system persist for more than a day. Stroke is divided into hemorrhagic (hemorrhage in the brain and / or its membrane) and ischemic (cerebral infarction).

Disturbances of cerebral circulation remain to date one of the most frequent and serious diseases of the nervous system. Recent epidemiological studies suggest that acute ischemic disorders of cerebral circulation continue to dominate the structure of cerebrovascular diseases, and cerebral infarction still develops 4 times more often than cerebral hemorrhage. The outcomes of a stroke are generally characterized by the following indicators: approximately 11% of patients require constant care, 53% are independent in everyday life, and 36% remain able to work [Suslina Z.A. et al. Ischemic stroke: blood, vascular wall, antithrombotic therapy. M., 2005, 248 p.].

In 2008, the Executive Committee of the European Organization for the Fight against Stroke published basic guidelines on the management of patients with ischemic stroke and transient ischemic attacks. They are based on a rehabilitation model that includes early (up to 14 days) patient mobilization. The topic of early rehabilitation of patients in the acute period of stroke is the subject of many articles and guidelines, but none of them contain a protocol for patient dental rehabilitation. While cognitive, speech, emotional-volitional, visual, sensory disturbances, physical weakness and lack of coordination, which often accompany a stroke, do not allow patients to maintain good oral hygiene at their own level [Sanossian N., et al. Subpar utilization of dental care among Americans with a history of stroke. Stroke Cerebrovasc Dis., 2011 May-Jun; 20 (3): 255-9]. This, in turn, leads to accelerated plaque formation and the development of periodontal diseases. Studies have revealed the association of periodontal diseases with pneumonia and cardiovascular diseases, as well as a negative impact on the health status of patients with cerebrovascular diseases [Terpenning M.S., et al. Aspiration pneumonia: dental and oral risk factors in an older veteran population, J Am Geriatr Soc, 2001 Mau; 49 (5): 557-63.5.6]. It is noted that professional oral hygiene is a preventive measure for the development of aspiration pneumonia in the elderly in the hospital, as it helps to reduce the level of methicillin-resistant Staphylococcus aureus in plaque [Mori C. et al. The effects of professional oral health care on patients in the subacute stage of emergent neurosurgical disorders., Spec Care Dentist., 2012 Nov-Dec; 32 (6): 259-6411], which is often the causative agent of nosocomial infections and is difficult to treat with standard types of antibiotics. A relationship was also noted between periodontogens and the development of atherosclerotic plaques in the vessels of the brain [Pyysalo M.J., et al. The connection between ruptured cerebral aneurysms and odontogenic bacteria. J Neurol Neurosurg Psychiatry. 2013 Nov; 84 (11): 1214-8. 5.26].

Thus, the participation of the dentist in the rehabilitation of patients after acute cerebrovascular insufficiency is obvious. However, among experts there is no consensus on the possible timing and volume of dental interventions in this category of patients. A number of authors recommend that dental interventions be postponed for 6-12 months, attributing to the fact that 70% of repeated episodes of stroke occur in the first month after the initial stroke. However, recent studies show that their causes are often associated not with cerebrovascular problems, but with the development of pneumonia, which the dentist can contribute to the prevention of [Bravata D.M. et al. Readmission and death after hospitalization for acute ischemic stroke: 5-year follow-up in the medicare population. Stroke 2007; 38: 1899-904].

To date, there is a known method of conducting dental surgery in patients a few weeks after the development of a stroke by examining the oral cavity to determine the volume of invasive dental interventions and monitoring them during the entire dental intervention [Elad S., Zadik Y., Kaufman E. , Leker R., Finfter O., Findler M. A new management approach for dental treatment after a cerebrovascular event: a comparative retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod., 2010; 110 (2): 145-50]. In the framework of this small retrospective study conducted in patients with stroke a few weeks after its development, it was concluded that dental treatment can be safe while these patients are under optimal medical supervision. However, reports that dental interventions can adversely affect the health of patients undergoing stroke, require the creation of the most optimal and safe process for their dental treatment for these people in the acute period of the disease, which is not described in this source of information.

The technical result of our proposed method is to minimize the trauma of dental interventions and reduce complications in patients with stroke in the acute period of the disease, due to the most sparing technique for these interventions.

The technical result is achieved by the fact that during dental interventions in patients with an acute period of stroke, an oral cavity is examined to determine the volume of dental interventions, then 30-60 minutes before the dental intervention, the patient is given a broad-spectrum antibiotic orally or by injection, and a dental the intervention is carried out at systolic pressure values of 135-145 mm Hg, with monitoring of blood pressure during the entire dental intervention in the position of the patient reclining angle of 35-50 degrees, wherein the regional anesthesia is carried out with a solution of 3% mepivacaine coupled infiltration anesthesia with 4% solution of articaine with epinephrine 1: 200,000 in a proportion of 3: 1.

Diseases of the teeth and oral cavity, leading to intolerable pain, or developing gradually, must be treated as soon as possible, because, as you know, the state of health of the teeth and oral cavity affect and determine the overall health of a person.

In this regard, the following pathological conditions of the teeth and oral cavity may be emergency dental interventions in patients in the acute period of stroke. As a rule, this applies to periodontal diseases (gingivitis, periodontitis), periodontitis, tooth cysts, pulpitis, caries and other diseases of the oral cavity and teeth, requiring immediate surgical treatment.

The method is as follows.

A patient with a cerebrovascular accident in the acute period should have a thorough medical history, an examination of the oral cavity to detect the presence of diseases of the teeth and oral cavity, and also in accordance with this volume of dental interventions.

In the presence of common diseases in the patient's history, the tactics of the proposed dental treatment are determined taking into account possible complications. If necessary, additional examinations are carried out (for example, biochemical blood tests, bleeding time, etc.) or a consultation with the patient’s doctor. If there is a suspicion of an allergy, they seek the conclusion of an allergist-immunologist about the tolerability of antibiotics and pain medications necessary for the treatment. Drugs are also introduced into the composition of medication preparations, corrective functions impaired by a concomitant disease. Establish a possible risk from dental treatment. When choosing a dental intervention, the psychoemotional and somatic state of the patient, as well as the volume, morbidity and duration of the planned intervention, are taken into account. Avoid creating stressful situations during treatment (short waiting time for admission, noise, bright light).

The developed technique is used in case of dental intervention requiring conduction and infiltration anesthesia. One of the broad-spectrum antibiotics is administered orally or by injection to the patient 30-60 minutes before the dental intervention, in particular, amoxicillin at a dose of 2 g in tablet form, if oral administration is not possible, 2 g of ampicillin or 1 g of cefazolin / ceftriaxone intramuscularly or intravenously. If you are allergic to penicillins - 2 g of cephalexin or 600 mg of clindamycin or 500 mg of azithromycin / clarithromycin orally. If oral administration is not possible, combined with an allergy to penicillins - 1 g cefazolin / ceftriaxone or 600 mg clindamycin intramuscularly or intravenously. This choice of antibacterial drugs is associated with their safety and activity against microflora, penetrating the systemic circulation. The patient is placed in a dental chair in a reclining position at an angle of 35-50 degrees. Given the anatomical prerequisites of cerebrovascular accident, sharp turns of the head and extension of the neck, as well as prolonged fixation in these poses are prohibited. Then measure blood pressure (BP) and with systolic blood pressure values of 135-145 mm Hg. carry out dental intervention. Only with the indicated blood pressure values can it be carried out in the optimal zone for all pathogenetic subtypes of stroke. A conduction anesthesia is carried out with a 3% solution of mepivacaine in combination with an infiltration anesthesia with a 4% solution of articaine with epinephrine 1: 200000 in a quantitative ratio of 3: 1, which allows for a safe and painless dental intervention. At the same time, blood pressure is monitored during the entire dental treatment. And the correction of blood pressure values is carried out with the participation of a neurologist.

After treatment, patients with a history of risk factors are given appropriate recommendations, taking into account concomitant pathology.

Examples of the implementation of the appointment.

Example 1

Patient Vorobyeva V., 54 years old, was admitted with a diagnosis of acute cerebrovascular accident with the development of a heart attack in the deep parts of the left hemisphere of the brain, arterial hypertension, atherosclerosis, type II diabetes mellitus, insulin-requiring diabetes.

On the 10th day of the disease, the patient complained of toothache. At the external examination, smoothness of the nasolabial folds on the right is noted. An oral examination was performed to identify the volume of dental interventions. On examination, slight deviation of the tongue to the right is noted. Tooth 4.8, mucosa of the alveolar gum in the tooth area is hyperemic, edematous, percussion is positive.

DS: Chronic periodontitis of the tooth 4.8 in the acute stage.

Preliminarily, 60 minutes before the dentist’s appointment, 1.0 g of cefazolin was administered intramuscularly. The patient was transported to the dental office and placed in a chair at an angle of 45 degrees. The measured blood pressure before dental intervention was 140/90 mm Hg, pulse 85 beats / min. A 4.8 tooth extraction was performed under mandibular anesthesia with a 3% solution of mepivacaine in an amount of 1.8 ml, as well as infiltration anesthesia with a 4% solution of articaine with epinephrine 1: 200000 in an amount of 0.6 ml, using a direct elevator and forceps 4.8. The curettage of the hole was performed, and hemostatic sponge was used for hemostasis.

Throughout the treatment, blood pressure of 145/90 mm Hg, pulse 85 beats / min.

The patient was in a satisfactory condition, both in the process and after treatment. Complications in the following days of the acute period were not noted.

Example 2

Patient Ch., 24 years old, was admitted with a diagnosis of acute cerebrovascular accident with the development of a heart attack in the brain stem. Bilateral dissection of the vertebral arteries.

On the 15th day of the disease, the patient complained of toothache. An oral examination was performed to identify the volume of dental interventions.

During external examination, there is a smoothness of the nasolabial folds on the left, deviation of the lower jaw to the right.

In the oral cavity: asymmetry of the soft palate (tongue deviates to the left), palatine and pharyngeal reflexes on the left. Irregularities were revealed in tooth 3.4, the coronal part of which was destroyed, the mucous membrane of the alveolar gum was hyperemic, edematous, and percussion was positive.

DS: Chronic periodontitis of the tooth 3.4 in the acute stage.

Preliminary, 60 minutes before the dentist's administration, amoxicillin was administered at a dose of 2 g orally. The patient was transported to the dental office and placed in a chair at an angle of 40 degrees. The measured blood pressure before dental intervention was 142/80 mm Hg, pulse 65 beats / min. Under anesthesia in the area of the mental opening with a 3% solution of mepivacaine in an amount of 0.9 ml, as well as infiltration anesthesia with a 4% solution of articaine with epinephrine 1: 200000 in an amount of 0.3 ml, a tooth was removed using a direct elevator and forceps 3.4. The curettage of the hole was performed, and hemostatic sponge was used for hemostasis.

Throughout the treatment, BP 144/87 mm Hg, pulse 75 beats / min.

The patient was in a satisfactory condition, both in the process and after treatment. Complications in the following days of the acute period were not noted.

Example 3

Patient L., 68 years old, was admitted with a diagnosis of acute ischemic lesions in the left hemisphere of the brain. On the 7th day there were complaints when taking hot and cold food in the lower jaw area on the left, passing immediately after elimination of the irritant. An oral examination was performed to identify the volume of dental interventions.

When examining the oral cavity in tooth 3.6, a carious cavity is noted, when probing the bottom is painful. The reaction to the cold is painful, fleeting. Percussion is painless.

DS: tooth dentin caries 4.6.

Treatment: pre-60 minutes before the dentist’s administration, 1.0 g of cefazolin was administered intramuscularly. The patient was transported to the dental office and placed in a chair at an angle of 45 degrees. The measured blood pressure before dental intervention was 140/90 mm Hg, pulse 85 beats / min. Under mandibular anesthesia with a 3% solution of mepivacaine in an amount of 1.8 ml, as well as infiltration anesthesia with a 4% solution of articaine with epinephrine 1: 200000 in an amount of 0.6 ml, a cavity was prepared, the drug was treated, a filling was made from a light-cured composite, polished and polished .

Throughout the treatment, blood pressure of 149/85 mm Hg, pulse 77 beats / min.

The patient was in a satisfactory condition, both in the process and after treatment. Complications in the following days of the acute period were not noted.

A total of 85 patients were treated in the acute period of cerebrovascular accident, including 20 patients with caries and its complications of pulpitis - to 5 patients and periodontitis - to 40 patients, and periodontitis - to 10 patients. All patients in the acute period of a stroke were pre-administered 30-60 minutes before the dental intervention with the introduction of broad-spectrum antibiotics. In particular, amoxicillin was administered at a dose of 2 g in the form of tablets, if oral administration was not possible, 2 g of ampicillin or 1 g of cefazolin / ceftriaxone intramuscularly or intravenously. If you are allergic to penicillins, 2 g of cephalexin or 600 mg of clindamycin or 500 mg of azithromycin / clarithromycin are administered orally. If oral administration is not possible, combined with an allergy to penicillins, 1 g of cefazolin / ceftriaxone or 600 mg of clindamycin was administered intramuscularly or intravenously. Dental intervention was performed at systolic pressure values of 135-145 mm Hg. with monitoring of blood pressure during the entire dental intervention. All patients were in the dental office, in a reclining position at an angle of 35-50 degrees. Conduction anesthesia was performed with a 3% solution of mepivacaine in combination with an infiltration anesthesia with a 4% solution of articaine with epinephrine 1: 200000 in a quantitative ratio of 3: 1. During administration and on the following days, complications were not observed in almost all patients (98%).

Thus, we have developed a more effective method of dental interventions in the acute period of stroke, ensuring minimal invasiveness of these interventions, and reducing complications due to the most sparing technique for their implementation.

Claims (1)

A method for carrying out dental interventions in patients with an acute period of stroke, including examining the oral cavity to determine the volume of dental interventions, characterized in that a patient is given a broad-spectrum oral or injection antibiotic 30-60 minutes before the dental intervention, and the dental intervention is performed at systolic pressure 135-145 mm Hg monitoring blood pressure during the entire dental intervention and in the position of the patient reclining at an angle of 35-50 degrees, while conduction anesthesia is carried out with 3% mepivacaine solution in combination with infiltration anesthesia with 4% articaine with epinephrine 1: 200000 in a quantitative ratio of 3: 1 .