NEET MDS Lessons
Oral Medicine
Emergency conditions in Dental Clinics
Faint - due to Pain or anxiety.
Signs and symptoms
• May be preceded by nausea and closing in of visual fields
• Pallor and sweating
• Heart rate below 60 beats/min (bradycardia) during attack.
T/t
• Give oxygen
• Expect prompt recovery.
• Need to encourage oxygenated blood flow to brain as rapidly as possible
• May need to block vagal activity with atropine and allow heart rate to increase.
If the patient is slow to recover, consider other diagnosis or give 0.3-1 mg atropine i.v.
Hyperventilation- due to Anxiety
Signs and symptoms
• Light-headed
• Tingling in the extremities
• Muscle spasm may lead to characteristic finger position (carpopedal spasm).
Treatment
• Reassure
• Ask patient to re-breathe from cupped hands or reservoir bag of inhalational sedation or general anaesthetic apparatus.
• Reduce anxiety
• Over-breathing has blown off carbon dioxide, resulting in brain blood vessel vasoconstriction. Return carbon dioxide levels in blood to normal.
Postural hypotension- More likely to occur if the patient is taking betablockers,which reduce the capacity to compensate for normal cardiovascular postural changes.
Signs and symptoms
• Light-headed
• Dizzy
• Loss of consciousness on returning to upright or standing position from supine position.
Treatment
Lay the patient flat and give oxygen
Sit the patient up very slowly.
Encourage oxygenated blood flow to brain.
Diabetic emergencies: hypoglycaemia- Patient may have taken medication as normal but not eaten before dental visit.
Signs and symptoms
• Shaking and trembling
• Sweating
• Hunger
• Headache and confusion.
Treatment
• If the patient is conscious, give three sugar lumps or glucose and a little water or glucose oral gel; repeated if necessary in 10 minutes
• If the patient is unconscious, inject 1 mg (1 unit) glucagon by any route (subcutaneous, intramuscular or i.v.).
Return blood glucose level to normal by giving glucose or by converting the patient's own glycogen to glucose by giving glucagon.
Further management
• Transfer the patient to A&E
• Give up to 50 ml 20% glucose i.v. infusion followed by 0.9% saline flush as the glucose damages the vein
• Expect prompt recovery.
Grand mal epileptic seizure- Usually the patient is a known epileptic
• Epilepsy may not be well controlled
• Seizure may be initiated by anxiety or by flickering light tube.
Signs and symptoms
- Sudden loss of consciousness associated with tonic phase in which there is sustained muscular contraction affecting all muscles, including respiratory and mastication
- Breathing may cease and the patient becomes cyanosed
- The tongue may be bitten and incontinence occur After about 30 seconds, a clonic phase supervenes, with violent jerking movements of limbs and trunk.
Treatment• Ensure patient is not at risk of injury during the convulsions but do not attempt to restrain convulsive movements
• Make no attempt to put anything in mouth or between the teeth
• After movements have subsided, place the patient in the recovery position and check airway
• The patient may be confused after the fit: reassure and offer sympathy
• After full recovery, send the patient home unless the seizure was atypical or prolonged or injury occurred.
• Maintain oxygenated blood to brain
• Protect from physical harm
• Administer anticonvulsant.
Further management
Risk of brain damage is increased with length of attack; therefore, treatment should aim to terminate seizure as soon as possible.
If convulsive seizures continue for 15 minutes or longer or are repeated rapidly (status epilepticus):
• transfer to A&E
• remove dentures, insert Guedel or nasopharyngeal airway
• give oxygen
• give 10-20 mg i.v. diazepam (2.5 mg/30 s) as Diazemuls but beware of respiratory depression, or diazepam solution for rectal administration in hospital.
Antibiotic protocol for prevention of endocarditis from dental procedures
Local or no anaesthesia
- Oral amoxicillin 3 g 1 hour before procedure
- if allergic to penicillin or have had more than a single dose in previous month: oral clindamycin 600 mg 1 hour beforeprocedure
- patients who have had endocarditis: amoxicillin and gentamycin, as under general anaesthesia
General anaesthesia: no special risk
- Amoxicillin 1 g intravenous at induction, then oral amoxicillin 500 mg 6 hours later
- oral amoxicillin 3 g 4 hours before induction then oral amoxicillin 3 g as soon as possible after procedure
- oral amoxicillin 3 g and oral probenecid 1 g 4 hours before procedure
General anaesthesia: special risk
- Patients with a prosthetic valve or who have had endocarditis are at special risk
- Amoxicillin 1 g and gentomycin 120 mg both intravenous at induction, then oral amoxicillin 500 mg 6 hours later
General anaesthesia: penicillin not suitable
- Patients who are allergic to penicillin or who have received more than a single dose of a penicillin in the previous month need different antibiotic cover
- Vancomycin 1 g intravenous over at least 100 minutes then intravenous gentamycin 120 mg at induction or 15 minutes before procedure
- teicoplanin 400 mg and gentamycin 120 mg both intravenous at induction or 15 minutes before procedure
- clindamycin 300 mg intravenous over at least 10 minutes at induction or 15 minutes before procedure then oral or
intravenous clindamycin 150 mg 6 hours later
Emergency conditions in Dental Clinics
Hypoadrenalism - Usually the patient is known to have Addison's disease or to be taking steroids long term and has forgotten to take the tablets.
Signs and symptoms
• Pallor
• Confusion
• Rapid weak pulse.
Treatment:
Give oxygen
Give 200 mg hydrocortisone sodium succinate by slow i.v. injection.
Give steroid replacement
Determining and managing underlying cause once the crisis over.
If required:
• Transfer to Emergeny hostpital
• Fluids and further hydrocortisone, both i.v.
Acute asthma - Exposure to antigen but precipitated by many factors including anxiety.
Signs and symptoms
• Persistent shortness of breath poorly relieved by bronchodilators
• Restlessness and exhaustion
• Tachycardia greater than 110 beats/min and low peak expiratory flow
• Respirations may be so shallow in severe cases that wheezing is absent.
Treatment
Excluded respiratory obstruction
Sit the patient up
Give oxygen
Salbutamol (Ventolin) via a nebuliser (2.5-5 mg of 1 mg/ml nebuliser solution) or via a large-volume spacer (two puffs of a metered dose inhaler 10-20 times: one puff every 30 seconds up to 10 puffs for a child)
Reassure and allow home if recovered.
• Bronchodilatation.
If Major Problem recommend to hospital Emergeny
• Hydrocortisone sodium succinate i.v.: adults 200 mg; child 100 mg
• Add ipratropium 0.5 mg to nebulised salbutamol
• Aminophylline slow i.v. injection of 250 mg in 10 ml over at least 20 minutes: monitor or keep finger on pulse during injection.
Caution in epilepsy: rapid injection of aminophylline may cause arrhythmias and convulsions.
Caution in patients already receiving theophylline: arrhythmias or convulsions may occur.
Anaphylactic shock
Signs and symptoms
• Paraesthesia, flushing and swelling of face, especially eyelids and lips (Fig. 13)
• generalised urticaria, especially hands and feet
• wheezing and difficulty in breathing
• rapid weak pulse.
These may develop over 15 to 30 minutes following the oral administration of a drug or rapidly over a few minutes following i.v. drug administration.
Treatment
Lay patient flat and raise feet
Give oxygen
Give 0.5 ml epinephrine (adrenaline) 1 mg/ml (1 in
1000) intramuscular
— 0.25 ml for 6-12 years
— 0.12 ml for 6 months to 6 years
repeated every 10 min until improvement.
Requires prompt energetic treatment of
• laryngeal oedema
• bronchospasm
• hypotension.
• Chlorphenamine (chlorpheniramine) 10 mg in 1 ml intramuscular or slow i.v. injection
• Hydrocortisone sodium succinate 200 mg by slow i.v. injection: valuable as action persists after that of adrenaline has worn off
• Fluids i.v. (colloids) infused rapidly if shock not responding quickly to adrenaline.
Stroke - Stroke results from either cerebral haemorrhage or cerebral ischaemia.
Signs and symptoms
• Confusion followed by signs and symptoms of focal brain damage
• Hemiplegia or quadriplegia
• Sensory loss
• Dysphasia
• Locked-in syndrome (aware, but unable to respond).
Treatment
Maintain and transfer for further investigation.
Benzodiazepine overdose - Overdose can result from a large or a fast dose of benzodiazepine or can occur in a sensitive patient.
Signs and symptoms
• Deeply sedated
• Severe respiratory depression.
Treatment
Flumazenil (Annexate) 200 mg over 15 seconds as 100 mg/ml i.v. followed by 100 mg every 1 minute up to maximum of 1 mg Maintain airway with head tilt/chin lift
Give oxygen.
Treatment
The action of the benzodiazepine is reversed with the specific antagonist.
Angina and myocardial infarction
Signs and symptoms
• Sudden onset of severe crushing pain across front of chest, which may radiate towards the shoulder and down the left arm or into the neck and jaw; pain from angina usually radiates down left arm
Skin pale and clammy
Shallow respirations
Nausea
Weak pulse and hypotension
If the pain not relieved by glyceryl trinitrate (GTN) then cause is myocardial infarction rather than angina.
First-line treatment of angina and myocardial infarction
Allow patient to rest in position that feels most comfortable:
• in presence of breathlessness this is likely to be the sitting position, whereas syncopal patients will want to lie flat
• often an intermediate position will be most appropriate.
Angina -
Angina results from reduced coronary artery lumen diameter because of atheromatous plaques
Myocardial infarction is usually the result of thrombosis in a coronary artery.
Angina is relieved by rest and nitrates:
• Glyceryl trinitrate spray 400 mg metered dose (sprayed on oral mucosa or under tongue and mouth then closed)
• Give oxygen
• Allow home if attack is mild and the patient recovers rapidly.
Myocardial infarction
If a myocardial infarction is suspected:
• give oxygen
• aspirin tablet 300 mg chewed.
• Pain control
• Vasodilatation of blood vessels to reduce load on heart.
Further management for severe angina or myocardial infarction
• Transfer to Emergency
• Diamorphine 5 mg (2.5 mg in older people) by slow i.v. injection (1 mg/min)
• Early thrombolytic therapy reduces mortality.
Cardiac arrest
• Most cardiac arrests result from arrhythmias associated with acute myocardial infarction or chronic ischaemic heart disease
• The heart arrests in one of three rhythms
— VF (ventricular fibrillation) or pulseless VT (ventricular tachycardia)
— asystole
— PEA (pulseless electrical activity) or EMD (electromechanical dissociation).
Signs and symptoms
• Unconscious
• No breathing
• Absent carotid pulse.
Treatment
• Circulation failure for 4 minutes, or less if the patient is already hypoxaemic, will lead to irreversible brain damage
• Institute early basic life support as holding procedure until early advanced life support is available.
• Transfer to Emergency
• Advanced life support.
Advanced life support for cardiac arrest
Advanced airway management techniques and specific treatment of the underlying cause of cardiac arrest constitute advanced life support (ALS).
Oral medicine is the specialty of dentistry concerned with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.
Oral medicine acts a focus for specialist interdisciplinary care of patients with symptoms arising from the mouth that do not relate directly to teeth.
These symptoms are often chronic and may have a significant psychological, as well as physical impact on the patient’s quality of life. In some instances, symptoms and signs reflect local problems restricted to the mouth. However, symptoms and signs can represent oral manifestations of more widespread disease.
Oral medicine practice depends on good diagnostic ability, in depth knowledge in identifying and removing the underlying cause from local, systemic ,genetic and environmental factors.
Oral physicians should adapt the demographic changes andmedical advancements with academic and research orientation for expansion of oral medicine and radiology andshoulder the responsibility of being part of patient's overall health care team.