RU2812880C1 - Method of forensic medical expert assessment of neurological consequences of dental treatment - Google Patents

Abstract

FIELD: medicine; namely forensic medicine.

SUBSTANCE: invention can be used for forensic medical assessment of the neurological consequences of dental treatment. To do this, electrogustometry (EGM), stereognosis of the oral cavity is performed, and a visual analogue pain scale (VAS) is used. The degree of neurological disorders resulting in disruption of their function with a persistent loss of general ability to work (PLGAW) is established as a percentage. if EGM indicators are from 0 to 50 mcA, stereognosis has 4-5 correct answers, VAS is 0-3 points, moderate peripheral damage to the trigeminal, facial, hypoglossal nerves is identified, resulting in a violation of their function with 5% PLGAW. If EGM indicators are from 51 to 80 mcA, stereognosis has 2-3 correct answers, VAS is 4-7 points, significant peripheral damage to the trigeminal, facial, hypoglossal nerves is identified, which entails a violation of their function with 15% PLGAW. If EGM indicators are from 81 to 200 mcA, stereognosis has 0-1 correct answer, VAS is 8-10 points, severe peripheral damage to the trigeminal, facial, hypoglossal nerves is identified, which entails a violation of their function with 25% of the PLGAW.

EFFECT: invention makes it possible to unify the application of criteria for permanent loss of general ability to work in expert practice through the reliability and objectivity of the forensic medical expert assessment of defects in dental treatment, thereby reducing the number of repeated forensic medical examinations.

1 cl, 2 tbl, 1 ex

Description

The invention relates to medicine, in particular forensic medicine, and can be used to formulate expert conclusions when conducting forensic medical examinations. Among commission forensic medical examinations, the largest number are traditionally examinations to determine the severity of harm caused to human health.

Harm caused to human health is understood as a violation of the anatomical integrity and physiological function of human organs and tissues as a result of exposure to physical, chemical, biological and psychogenic factors of the external environment (Forensic medical examination of harm to health: a guide / [V.A. Klevno et al. ]; edited by Prof. V.A. Klevno. - M.: GEOTAR-Media, 2009. - P. 5.) Currently, when conducting forensic medical examinations, in dentistry in particular, medical criteria are used to determine the degree of severity harm caused to human health (Approved by order of the Ministry of Health and Social Development of the Russian Federation dated April 24, 2008 No. 194n).

When conducting forensic medical examinations, special attention is paid to the nature of the injury (disease), its primary clinical manifestations, early and late complications (Forensic medicine and forensic medical examination: national manual / edited by Yu.I. Pigolkin. - M. : GEOTAR-Media, 2014. - 728 p.: ill.).

When conducting forensic medical examinations, in particular after dental interventions, experts use medical criteria for determining the severity of harm caused to human health (hereinafter referred to as Medical Criteria), developed in accordance with the Decree of the Government of the Russian Federation of August 17, 2007 No. 522 “On approval of the Rules for determining the severity of harm caused to human health.”

According to clause 17, clause 18 of the “Criteria...” “A health disorder consists of a temporary disruption of the functions of organs and (or) organ systems, directly related to damage, disease, pathological condition, which causes temporary disability. The duration of dysfunction of organs and (or) organ systems (temporary disability) is established in days based on objective medical data, since the duration of treatment may not coincide with the duration of restriction of the functions of organs and (or) human organ systems. The treatment provided does not exclude the presence in a living person of post-traumatic limitation of the functions of organs and (or) organ systems.”

The disadvantage of these criteria is the impossibility of determining, based on objective and subjective parameters, the extent of dysfunction of the maxillofacial apparatus after dental interventions complicated by neurological symptoms, i.e. decrease or complete absence of all types of sensitivity on the face and in the oral cavity, absence or decrease in taste sensations, pain of varying duration, impaired chewing function, etc. In the currently used “Table of Percentages of Persistent Loss of General Working Capacity (SUOT) as a result of various injuries, poisonings and other consequences of external causes” in paragraph 9 “Peripheral damage to the trigeminal, facial, hypoglossal nerves, resulting in disruption of their function: a) moderate - 5% OHS; b) significant - 15% OHS; c) sharp - 25% SUOT.

Modern dentistry has a significant arsenal for studying the neurological status of patients:

- Electrogustometry (EGM). This method is based on determining the threshold values of the current strength that causes a specific taste sensation of sour when irritating the taste points of the tongue. Using the “Electroodontometer EOM-3” device, the active electrode is applied to the lateral surface of the front part of the tongue, the passive electrode is clamped in the hand of the subject. Before recording the results of the EGM study, it is proposed to familiarize yourself with the sensation of touching both halves of the tongue with a metal electrode, which is applied alternately to the lateral sections of the tongue on the right and left at a distance of 1.5 cm from the midline in order to exclude the possibility of irritation of the opposite side. Then the current in the circuit gradually increases from zero to a value at which a taste sensation appears on the tongue. The threshold is the minimum strength of the applied current that causes a sensation, and is recorded visually by the movement of the microammeter needle. In this case, the patient does not see the microammeter scale. To exclude adaptation to the stimulus, the duration of irritation of the tongue with electric current should not exceed 2 seconds. 5 measurements are performed, the average of which is taken as the threshold value. A decrease in taste in an area of the tongue with a higher threshold is considered a difference in thresholds of 20 μA, and the absence of taste sensation when the tongue is irritated with an electric current of 300 μA is considered a loss of taste. When conducting EGM, it is considered mandatory to take into account the time elapsed after eating, because taste thresholds fluctuate: on an empty stomach they are lower, and immediately after eating they increase. Therefore, to ensure the reliability of the results, all studies are carried out on an empty stomach. (Yamashev I.G. Study of taste sensitivity in patients with schizophrenia using electrogustometry / I.G. Yamashev, L.E. Ziganshina, R.Yu. Ilyina // Materials of the X International Conference of Maxillofacial Surgeons and Dentists, May 24-26 - St. Petersburg, 2005. - pp. 221-222; Borisova E.G. Chronic pain and paresthetic syndromes of the tongue: clinical picture, diagnosis, treatment, prevention and organization of the treatment process: dissertation... Doctor of Medical Sciences: 14.01. 14. - VSMA named after N.N. Burdenko. - Voronezh, 2015. - 225 p.).

- Study of stereognosis of the oral cavity in persons with trigeminal neuralgia (Borisova E.G. Diagnosis and treatment of pain syndromes of the face and oral cavity in an outpatient setting / E.G. Borisova. - Voronezh: VSU Publishing House, 2011. - 128 p. .), glossalgia (Borisova E.G. Chronic pain and paresthetic syndromes of the tongue: clinical picture, diagnosis, treatment, prevention and organization of the treatment process: dissertation... Doctor of Medical Sciences: 01/14/14. - VSMA named after N.N. Burdenko. - Voronezh, 2015. - 225 p.). The study is carried out on an empty stomach, in the morning, at room temperature 18-20°C. One of seven figures made of alloyed stainless steel grade 1Х18Н9Т, a set (ball, pyramid, cube, square, circle, triangle, oval), is placed on the back of the tongue of the patient. The second such set is placed out of sight of the patient. The assistant places the figure on the tongue and at the same time points to the same figure of the second set (for control). Within 10 seconds, the patient must determine by his feelings what kind of figure it is. The number of correct (+) and incorrect (-) answers is taken into account.

These methods have never been used to interpret defects (deficiencies) during forensic medical examinations after dental interventions complicated by neurological symptoms (constant aching or short-term burning pains radiating along the branches of the trigeminal nerve, impaired sensitivity, both superficial, temperature, and taste, inability to eat properly, speak due to painful attacks, headaches, tinnitus, pain when opening the mouth, dizziness, insomnia, irritability, anxiety, etc.)

The method we have developed allows us to objectify the results of forensic medical examinations in cases of defects (deficiencies) arising after dental interventions complicated by neurological symptoms.

The solution to this problem is ensured by the fact that in the method of forensic medical expert assessment of the neurological consequences of dental treatment, electrogustometry, stereognosis of the oral cavity and a visual analog pain scale are used, when using which the degree of neurological disorders is determined according to electrogustometry indicators: from 0 to 50 μA - moderate disorders, from 51 µA to 80 µA - significant violations, from 81 µA to 200 µA and above - sharp violations, according to stereognosis indicators: 4-5 correct answers - moderate violations, 2-3 - significant violations, 0-1 - severe violations, according to indicators of the visual analog pain scale: from 0 to 3 points - moderate impairment, from 4 to 7 points - significant impairment, from 8 to 10 points - severe impairment.

Comprehensive forensic medical examinations of 57 patients with neurological complications that arose after dental treatment showed the following results (Table 1):

As follows from Table 1, in all 57 patients with neurological symptoms that arose after dental interventions, there was a significant (p <0.05) decrease in SG and EGM indicators compared to healthy individuals (without pain and paresthesia in the tongue, on the mucous membrane oral cavity and other neurological symptoms).

The intensity of pain is assessed using a visual analogue scale (VAS), which is based on the patient’s subjective assessment of their pain sensations. In this case, a score of “0” points corresponds to the absence of pain, and “10” points are regarded as “unbearable” pain. From 0 to 4 points - moderate pain (moderate disturbances), from 4 to 7 points - severe pain (significant disturbances), from 7 to 10 points - unbearable pain (severe disturbances).

Our proposed method for forensic medical assessment of the neurological consequences of dental treatment consists of comparing dental methods for studying the neurological status and the degree of dysfunction of peripheral nerves according to the “Table of percentages of permanent loss of general

disability as a result of various injuries, poisonings and other consequences of external causes.”

The ratio is shown in Table 2.

Thus, the technical result of the claimed method is to increase the reliability and objectivity of the forensic medical expert assessment of the shortcomings (defects) of dental treatment.

The technical result is achieved by the fact that in the method of forensic medical expert assessment of the neurological consequences of dental treatment, electrogustometry, stereognosis of the oral cavity and a visual analogue pain scale according to the proposed method are used to objectify the criteria for defects (deficiencies).

Example 1. Patient 3., 27 years old. After treatment, removal, depulpation of teeth and prosthetics at the dentist, by court order, she was sent for examination to a forensic expert and specialist with complaints of constant dull pain at night and during the day in the area of the right and left temporomandibular joints, in the temporal region, in right and left ear, behind-the-ear areas, outer corners of the right and left eye, worsening with the slightest movement of the lower jaw. Inability to chew food. Constant aching pain in all teeth, gums, impaired sensitivity of the tongue on the right, taste disturbances. During any movement of the lower jaw, a crunch occurs in the temporomandibular joints on the right and left (usually on the right), dizziness, darkening of the eyes, ringing in the ears; periodic numbness of the right and left cheek areas, during which the 5th, 4th, 3rd fingers of the right hand go numb and the face turns red; feeling that “the neck is constantly being pulled to the right”,

On examination, there is asymmetry of the face due to the displacement of the chin to the right, the skin is of normal color, the regional lymph nodes are not enlarged and painless. On palpation - sharp pain (trigger points) in the right and left masticatory, lateral and medial pterygoid muscles, in the middle portion of the temporal muscles, the right sternocleidomastoid muscle (anterior head), the right and left trapezius muscles. Palpation in the area of projection of the heads of the right and left temporomandibular joints is painful. Vertical, sagittal and transversal movements in the right and left joints are limited and severely painful. Mouth opening is 2.5-3 cm, with a norm of 4-5 cm. The mucous membrane of the oral cavity is physiologically colored, moist, shiny; there are 1.6 on the upper jaw. tooth, roots of 1.4, 1.2, 1.1, 2.1 teeth, sealed at the apexes, the remaining teeth are missing, gingival papillae in the area of roots 1.4, 1.2, 1.1, 2.1 are hyperemic, swollen, and bleed on probing. Closing the jaws in a position of central occlusion leads to severe pain in the temporomandibular joints. The bite is not determined. Stereognosis indicators - 4 positive answers out of 7, electrogustometry indicators - 58.3 μA, VAS indicators - 5 points.

Deterioration of health 3., expressed in the loss of 9 teeth, impaired chewing function, progression of inflammatory-destructive processes in the temporomandibular joints, and peripheral damage to the facial and hypoglossal nerves, resulting in a significant impairment of their function (15% of SUOT); due to a combination of disadvantages of endodontic treatment and irrational prosthetics. Therefore, there is a direct cause-and-effect relationship between the medical services provided and the occurrence of adverse consequences.

Claims (1)

A method of forensic medical expert assessment of the neurological consequences of dental treatment, characterized in that they perform electrogustometry (EGM), stereognosis of the oral cavity, use a visual analogue pain scale (VAS), establish the degree of neurological disorders resulting in disruption of their function with a permanent loss of general ability to work. in percentage, with EGM indicators from 0 to 50 μA, stereognosis 4-5 correct answers, VAS 0-3 points, moderate peripheral damage to the trigeminal, facial, hypoglossal nerves is established, resulting in a violation of their function with 5% SUOT, with EGM indicators from 0 -1 correct answer, VAS 8-10 points indicate severe peripheral damage to the trigeminal, facial, and hypoglossal nerves, which resulted in a violation of their function with 25% of the SUOT.