Published on March 7, 2014
Oral Surgery PROBLEM BASE LEARNING
The Case A Patient Present To Your Clinic For Initial Visit Complain From Pain Related To Upper Left Molar Teeth. When Reviewing The Patient Medical History Reported Of Renal Dialysis.
Problem Renal dialysis. Pain related to upper left molar teeth.
Case discussion 1) Patient on dialysis is medically compromised as he suffers from: 1. Renal failure: Dec. RBCs count. Problem with WBCs. Platelet Dysfunction. Water / electrolyte imbalance. 2. Patient on heparin for dialysis. 3. At risk of infection with HIV and Hepatitis.
2) Pain in the upper left molar teeth: Probable types of pain : Odontogenic origin: • Hyperemia. • Pulpitis: • Cracked tooth. • Periapical pathosis: • gingivitis: • Periodontitis. • Third molar impaction. Paraodontogenic origin: MAXILLARY SINUSITIS.(The most probable cause of the complain) X Eye Glaucoma. X Salivary gland swelling.
Musculoskeletal. Neurogenic : - Trigeminal neuralgia of maxillary branch. Neuritis. Vascular: Migraine. Cluster headache. CV problem: 1. Angina. 2. Myocardial infarction.
Diagnosis • History (already taken from the patient): - Renal failure. - Pain related to upper molar teeth. • Clinical examination: - Intraoral. - Extraoral.
• Intraoral: 1. Inspection of the general oral condition of the pt. (patient with kidney problems often suffers from halitosis, ammonia odour). 2. Palpation(No swelling). 3. Percussion : pain was found on percussion. 4. Probing. • 1. Extraoral: Palpation(Bimanual & Bidigital): Tenderness over maxillary sinus. 2. S.G Examination. 3. TMJ Examination. 4. Masticatory muscles examination: Temporalis Examination. Buccinators & Orbicularis oris.(Tenderness was found in cheek muscles).
• Blood Pressure Measurement : - One should never operate on uncontrolled patients. • Radiographic Aids: - Periapical. - Bitewing. - Panoramic. - Waters View radiograph for maxillary sinus Examination. • Lab investigations: - CBC. - Coagulation profile(PTT, PT and INR) - ELISA method for detection of Antibodies for AIDs & HIV.
Treatment Planning Control Medical condition of the patient: Problem Management Anemic Pt. Blood transfusion Dec. WBCs Prophylactic Antibiotics Platelets dysfunction Referral to treating Physician High Blood pressure Antihypertensive drug Don’t Inc. Vasoconstrictor in AG more than 0.04 Heparin Stop heparin intake Before Surgery and organize with the treating physician.
• Stress reduction protocol: 1. Recognize the patient's degree of medical risk. 2. Complete medical consultation before dental therapy. 3. Schedule the patient's appointment in the morning. 4. Monitor and record preoperative and postoperative vital signs. 5. Use psychosedation during therapy. 6. Use adequate pain control during therapy. 7. Short length of appointment: do not exceed the patient's limits of tolerance. 8. Follow up with postoperative pain/anxiety control. • Actual treatment of Maxillary sinusitis: Surgically(Curettage). Naso-antral drainage. Treatment with antibiotics(penicillin and derivatives). Referral to ENT physician.
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