TOPIC I. ETIOLOGY AND PATHOGENESIS OF ODONTOGENIC INFLAMMATORY
DISEASES. CLASSIFICATION OF INFLAMMATORY DISEASES OF THE
MAXILLOFACIAL AREA
Place of study - Dental clinic. Surgical office. Lesson duration - 180 min. Purpose of the lesson
1.
Study the etiology and pathogenesis of odontogenic inflammatory diseases.
2.
Study the classification of inflammatory diseases of the maxillofacial area.
Etiology and pathogenesis of odontogenic inflammatory diseases
Inflammatory diseases of the maxillofacial area are by their nature infectious-inflammatory processes, i.e.
they are caused by microbes, most of which under normal conditions grow on the skin and mucous
membrane of the oral cavity.
The causative agents of odontogenic inflammatory diseases are microorganisms that are usually part of the
permanent microflora of the oral cavity: staphylococci, streptococci, enterococci, diplococci, Pepto cocci,
Pepto streptococci, gram-positive and gram-negative bacilli. In addition, fungi, mycoplasmas, protozoa from
the Trichomonas family, and spirochetes are sometimes found in foci of odontogenic infection. The
microflora of foci of odontogenic infection is most often represented by a monoculture of staphylococcus or
streptococcus. Associations of staphylococcus with streptococcus and gram-negative bacilli are often found.
When the integrity of the skin and mucous membrane is damaged, the marginal periodontium is damaged, as
well as the destruction of the hard tissues of the tooth with the opening of its cavity, these microbes penetrate
into the underlying tissues. Their further fate may be different. In some cases, they die in the zone under the
influence of protective factors, in others, with the flow of lymph they reach the lymph nodes, where they are
destroyed. If the lymph nodes are unable to completely fix and destroy microbes, the latter penetrate into the
bloodstream and can be carried into any organ through the bloodstream. However, a different outcome is
often observed. Microbes that have entered the tissue adapt to new living conditions and begin to multiply. A
number of them are about
3
produces toxic substances of protein nature - exotoxins, which have antigenic properties and are capable of
selectively affecting certain tissues.
As a result of the death and decay of the microbial cell, toxic substances are also released from it endotoxins, which are not characterized by specificity. By causing damage to tissue structures, toxins thereby
cause the development of an inflammatory reaction aimed at limiting the area of spread of microbes, their
destruction and elimination. With the appearance of the first signs of this reaction, one can speak of the
beginning of a local infectious process. Its occurrence depends on the virulence of the infectious origin, as
well as on the level of immunological reactivity of the body.
Acute periodontitis
(primary, exacerbation
chronic)
Acute osteitis (periostitis,
transient form
inflammation)
4
Acute osteomyelitis. (purulent-necrotic
process)
I1
Purulent-inflammatory processes
in soft tissues (subperiosteal
abscess, phlegmon,
subcutaneous granuloma)
Chronic osteitis:
a)
refining, including
including "dry"
Garre's osteomyelitis;
b)
hyperplastic
Chronic osteomyelitis
4
Scheme 1. Development of odontogenic inflammatory processes
The infectious process serves as a manifestation of the interaction of micro- and macroorganisms; the
properties of microbes to a certain extent influence the nature of the course of the infectious-inflammatory
process, causing certain features of the manifestation of the disease. For example, it has been established that
in patients with such limited forms of acute odontogenic infection as periodontitis, periostitis, the microflora
of the infectious focus is more often represented by streptococci, and in patients with phlegmons and
abscesses, osteomyelitis - staphylococci or an association of staphylococcus with other microorganisms.
The nature of the course of the infectious-inflammatory process depends not only on the species of the
pathogens, but also on their cultural properties. With odontogenic infection caused by pathogenic strains of
staphylococcus, the development of osteomyelitis of the jaws is more often observed, while strains of
anaerobic microorganisms usually cause the occurrence of perimaxillary phlegmon.
However, the penetration of pathogens of purulent infection into the tissues of the macroorganism does not
yet mean the inevitable occurrence of an infectious-inflammatory process, assessed as a disease. To “start” a
local infectious-inflammatory process, a certain “critical concentration” of the causative agent of the disease
is required. The infectious-inflammatory process serves as a manifestation of the interaction of two
principles: on the one hand, pyogenic microflora, on the other, a macroorganism with its inherent ability to
respond to the influence of this microflora.
Classification of inflammatory diseases of the maxillofacial region
The classification of inflammatory diseases of the maxillofacial region is based on clinical and morphological
signs.
5
Tables"
1
Classification of inflammatory diseases of the maxillofacial region and neck
Source and nature of infection
Disease
Form of the disease
1
Odontogenic
2
Periodontitis
Spicy:
Serous
Purulent
Chronic: fibrous granulating granulomatous Chronic in the acute stage
Periostitis of the jaw
Osteitis of the jaw
Spicy:
Serous
Purulent
Acute (reactive)
but-transient
form)
Chronic (osifying)
Chronic:
reifying
hyperplastic
Osteomyelitis of the jaw
Abscesses and cellulitis
Acute Subacute
Acute stage
Chronic Primary chronic Chronic in the acute stage
Subacute stage
Lymphadenitis, nonspecific
Sinusitis
Spicy:
Serous
Purulent
Abscessing
Adenophlegmon
Acute Subacute
Chronic: productive productive in the acute stage
Chronic Chronic in the acute stage
1
23
Neodontogenic Furuncle and carbuncle of the faceAcute stageAcute stage
Hematogenous osteomyelitisAcute SubacuteChronic Chronic in the acute stage
Traumatic osteomyelitisAcute SubacuteChronic Chronic in the acute stage
Sialadenitis
(calculous,
non-calculous) Acute SubacuteChronic Chronic in
stage of exacerbation
TMJ ArthritisAcuteChronic
Abscesses and cellulitisAcute stageAcute stage
LymphadenitisAcuteChronic
Specific infection
Actinomycosis
Tuberculosis
Syphilis
Control questions
1.
Indicate possible sources of infection of inflammatory diseases of the maxillofacial area.
2.
What factors influence the occurrence and development of infectious and inflammatory processes?
3.
Pathogenesis of odontogenic inflammatory diseases.
4.
What signs form the basis for the classification of inflammatory diseases of the maxillofacial area?
Tests
1. Sources of infection localized in the tissues surrounding the tooth are called:
a)
stomatogenicc) tonsilogenic
b)
odontogenic
7
2.
The most common cause of the development of inflammatory processes
there is an infection in the maxillofacial area
a)
odontogenicc) dermatogenic
b)
tonsilogenic
3.
The most common causative agents of odontogenic inflammatory diseases
processes are
a)
coccius) anerobes
b)
gram-negative rods
4.
Toxic substances of protein nature released by micro¬
organisms are called
a) exotoxins
b) endotoxins
5.
Toxic substances released during the death of microbial
cells are called
a) exotoxins
b) endotoxins
6.
The most common cause of development of acute odontogenic
the inflammatory process is
a)
acute periodontitis
b)
exacerbation of chronic periodontitis
7.
Specify the inflammatory process of non-odontogenic etiology
a)
lymphadenitisc) boil
b)
osteomyelitis
8.
Specify the inflammatory process of non-odontogenic etiology
a)
phlegmon) sialadenitis
b)
periostitis
9.
The causative agents of specific inflammatory processes are
lie
a)
cocci) actinomycetes
b)
gram-negative rods
10.
The causative agents of specific inflammatory processes are
lie
a)
anaerobes
b)
protozoa
c)
Mycobacterium tuberculosis
Situational tasks
Task 1. A patient came to the hospital with a referral diagnosis: “Osteomyelitis of the lower jaw.” According
to the patient, he has been ill for 1 year. A decayed tooth 46 is identified in the oral cavity.
Formulate a correct diagnosis, taking into account the principles of classification of inflammatory diseases of
the maxillofacial area.
Task 2. A patient was admitted to the maxillofacial surgery department with a diagnosis of “Phlegmon of the
submandibular region on the right.”
) Does the etiology of the inflammatory process matter for drawing up a treatment plan?
2. What examination needs to be carried out to establish the etiology of the disease?
TOPIC 2. IMMUNOBIOLOGICAL FEATURES OF TISSUES OF THE MAXILLOFACIAL
REGION. THE INFLUENCE OF ANTIBACTERIAL RESISTANCE OF ORAL TISSUES ON
THE DEVELOPMENT OF ODONTOGENIC INFECTION
Place of practice: Dental clinic. Surgical office. Lesson duration - 180 min. Purpose of the lesson
1.
Study the immunobiological characteristics of the tissues of the maxillofacial area.
2.
To study the effect of antibacterial resistance of oral tissues on the development of odontogenic
infection.
In a healthy person, the species composition of the microflora of the oral cavity is constant, and only the
number of microbes can change significantly, which depends on salivation, the nature of the food eaten, the
hygienic maintenance of the oral cavity, and the presence of somatic diseases.
The microbial profile is quite diverse and includes bacteria, actiomycetes, protozoa, fungi, spirochetes,
viruses, and rickettsia. Representatives of anaerobic microflora dominate. The most numerous among the
microflora of the oral cavity are streptococci (up to 90%), most of which are facultative anaerobes. These
bacteria suppress the growth of putrefactive microorganisms that enter the oral cavity from the environment.
Streptococci, leptotrichia, lactobacilli, thanks to the production of lactate, inhibit the growth of staphylococci,
E. coli, typhoid and dysentery bacilli.
In the oral cavity of a healthy person there are radiant fungi, yeast-like fungi of the genus Candida.
The number of microorganisms living in the oral cavity is in a state of dynamic equilibrium thanks to the
antibacterial factors of saliva and leukocytes that have migrated into the oral cavity. Saliva, due to its
antibacterial properties, is able to reliably control the amount
9
the qualitative composition of the microflora and thereby maintain the micro-ecological balance of the oral
cavity.
The protective mechanisms of the oral cavity include nonspecific and specific (immune) resistance factors.
Nonspecific factors pe3HCTeHTjHnrTiL (pp4Hf-TPHTHocTb - a set of genetically determined nonspecific
protective factors that provide immunity to infections) are the first to “stand up” for protection under the
influence of pathogenic (most often infectious) agents. Resistance factors include:
1.
Natural barriers: skin and mucous membranes are the surfaces that first come into contact with
pathogenic factors.
2.
The phagocyte system, including neutrophils and macrophages.
3.
The complement system (a set of serum proteins), which closely interacts with phagocytes.
4.
Interferon.
5.
Various substances, most often of a protein nature, involved in the reactions of inflammation,
fibrinolysis and blood coagulation. Some of them (for example, lysozyme) have a direct bactericidal effect.
6.
A system of natural killers that do not have antigenic specificity (T-killers + M<-cells).
The skin and mucous membranes, being intact, are impermeable to most microorganisms. The ability of the
skin to desquamate cells provides mechanical removal of the infection, and the effect of lactic acid and fatty
acids contained in sweat and sebaceous gland secretions is destructive for most bacteria with the exception of
Staphylococcus aureus.
The secretion secreted by the mucocellular apparatus of the salivary glands, the mucous glands of the mucous
membranes, acts as a protective barrier, preventing the attachment of bacteria to epithelial cells and
mechanically removing them due to the movement of the epithelial cilia.
The flushing effect of saliva and tears helps protect the surface from damage caused by pathogenic agents.
Many biological fluids secreted by the body contain substances that have bactericidal properties (for
example, lysozyme in saliva, tears).
Normal oral microflora inhibits the growth of potentially pathogenic microorganisms due to competition for
nutrients or the production of certain substances (acids). The filtration function of the lymph nodes is
protective.
10
The system of phagocytes, as nonspecific resistance factors, is represented by two types of cells: microphages
(neutrophils) and macrophages. As a result of stimulation of the surface of neutrophils, an outbreak of
oxidative reactions occurs in them and a large number of metabolites and hydrolytic enzymes that destroy
microorganisms accumulate.
However, with a high density of neutrophils per unit volume of tissue, their self-activation occurs and the
formation of foci of infiltrated tissue (abscesses, boils).
Macrophages are characterized by high phagocytic activity. Monocytes can promote both inflammatory and
anti-inflammatory processes, influence the complement system, and have a toxic effect on tumor cells and
microorganisms.
The complement system is a complex complex of serum proteins. Of the total amount of whey proteins, the
complement system accounts for 10%. It is the basis of the body's defenses. Complement participates in the
regulation of humoral immunity. In addition, the complement system is an important factor in natural
resistance against viral infection.
Bactericidal humoral factors. Among the soluble bactericidal compounds produced by the body, the most
common enzyme is lysozyme. It breaks down muromic acid, which is part of the membrane of gram-negative
bacteria, which leads to lysis of the bacterial cell walls.
Lactoferrin also belongs to the bactericidal humoral factors. This is a protein contained in special granules of
neutrophils.
Interferons are antiviral agents synthesized by lymphocytes and macrophages. By forming a barrier of
uninfected cells around a viral infection, it limits its spread.
Normal killer cell system (T-killer cells + MK cells). They are large granular lymphocytes and have a
nonspecific toxic effect on the cells of some tumors and normal tissues. They function as effectors of
antiviral immunity. K cells are effector cells that have antibody-dependent cytotoxicity. Granulocytes,
macrophages, monocytes, and platelets can function as K cells.
Immunoreactivity (specific resistance) of the oral cavity is provided by secretory Ig A contained in saliva,
oral and gingival fluid. Ig A is the main type of immunoglobulins involved in local immunity. In the oral
cavity, they prevent bacteria from attaching to the mucous membrane and tooth surface, and activate
phagocytosis and complement.
eleven
Thanks to the close interaction of specific and non-specific resistance factors, the body, including the oral
cavity, is reliably protected from infectious and non-infectious pathogenic factors of the external and internal
environment.
Control questions
1. Indicate the anatomical and physiological features of the maxillofacial* region.
2.
What factors include the protective mechanisms of the oral cavity?
3.
What factors of nonspecific resistance are identified?
4.
What ensures the specific resistance of the oral cavity?
5.
How is the balance of the quantitative and qualitative composition of the microflora living in the oral
cavity ensured?
Tests
1.
The species composition of the microflora of the oral cavity of a healthy person is a) constant b)
variable
2.
Most numerous among oral microorganisms
a)
streptococci) actinomycetes
b)
staphylococci
3.
Antibacterial factors of saliva in terms of quantity and quality
vein composition of oral microorganisms
a) do not influence
b) influence
4.
To nonspecific factors of resistance of the oral cavity from
rush around
a)
mucous membrane c) immunoglobulins
b)
phagocyte system
5.
To non-specific factors of resistance of the oral cavity from
rush around
a)
complement systemc) immunoglobulins
b)
interferons
6.
Bactericidal-humoral factors include a) lysocymbus) mucin
7.
Bactericidal-humoral factors include a) parotin b) lactoferrin
8.
Macrophages are
a) neutrophils b) monocytes
9.
Microphages are
a) neutrophils b) basophils
12
10 Immunoglobulins responsible for local immunity in the
6)IgG r)'gE
Situational tasks
Task 1 - A patient with an inflammatory disease independently took antibiotics in large doses.
1 What consequences can lead to uncontrolled self-medication with antibiotics?
2. Indicate possible preventive measures.
Task 2. A patient who carefully observes oral hygiene, diet, and leads a healthy lifestyle often experiences
inflammatory diseases of the oral cavity and gastrointestinal tract.
1.
What pathology can be assumed in this patient?
2.
What examination needs to be carried out to clarify the nature of the pathological condition?
3.
Make a treatment plan.
TOPIC 3. WAYS OF SPREAD OF ODONTOGENIC INFECTION. CAUSES OF
EXACERBATION OF CHRONIC ODONTOGENIC INFECTION
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the ways of spread of odontogenic infection.
2.
To study the causes of exacerbation of chronic odontogenic infection.
Ways of spread of odontogenic infection
The spread of odontogenic infectious-inflammatory progress from the zone of its primary localization
(periodontal) can occur along the length, lymphogenously or hematogenously.
J spread of the infectious-inflammatory process along the
niya can sometimes be identified with the spread of pus. Gnsht^obra^
^ present in the periodontium, melts the associative tissue, penetrates through the
RU compact layer under the periosteum, and after melting the periosteum
interfascial spaces adjacent to the jaw. However, only
it is difficult to explain the occurrence of rapidly occurring
13
forms of acute odontogenic infection, in which, without previous destruction of bone tissue, inflammatory
phenomena in the perimaxillary soft tissues develop literally within a few hours after the onset of the disease.
Consequently, what is happening here is not so much the spread of pus, but rather the spread of serum
protein, which has antigenic properties, into the adjacent soft tissues.
Through osteon channels and nutrient channels, antigens reach the richly vascularized periosteum and
interfascial tissue. The presence of a dense network of capillaries facilitates the penetration of antigens
through their wall into the vascular bed. Here they combine with antibodies circulating in the blood and form
complexes, the presence of which causes the occurrence of an immunopathological reaction similar to the
Arthus-Sakharov phenomenon with its characteristic endothelial damage, intravascular coagulation, impaired
microcirculation, tissue necrosis and the subsequent development of inflammation.
Naturally, thinning, and even more so destruction of the compact layer of the jaw as a result of previous
chronic periodontitis, facilitates the spread of microorganisms and their metabolic products that have
antigenic properties. In addition, the destruction of bone tissue largely determines the localization of the
infectious and inflammatory process in the perimaxillary soft tissues.
Causes of exacerbation of chronic odontogenic infection
An important role in maintaining the dynamic balance between the focus of chronic odontogenic infection
and the patient’s body belongs to the connective tissue capsule surrounding such a focus. It limits the spread
of microbes and their metabolic products into the tissues adjacent to the lesion and their entry into the
vascular bed. At the same time, the connective tissue capsule makes it difficult for the factors of cellular and
humoral immunity to influence the infectious focus. Maintaining balance is also facilitated by the fact that
part of the waste products of microbes and tissue decay through the root canal, fistula or periodontal fissure is
eliminated from the infectious focus into the oral cavity.
What can disrupt the established balance and cause an exacerbation of inflammatory phenomena and the
spread of the infectious process beyond its original boundaries? The answer to this question is of great
practical importance, as it allows us to outline ways to prevent such complications and their rational
treatment.
14
One of the reasons is the increase in the virulence of microflora due to disruption of the outflow pathways of
exudate through the root canal due to accidental entry of food masses into the carious cavity or deliberate
obturation of it with filling material. In the infectious focus, the concentration of microbes, their toxins and
tissue decay products increases, which, according to the laws of osmosis and diffusion, begin to penetrate to a
greater extent through the connective tissue capsule into the adjacent tissues and have a pathogenic effect.
Clinically, this is expressed as an exacerbation of chronic periodontitis or the development of another form of
acute odontogenic inflammation. Obstruction of the outflow tract also creates favorable conditions for the
development of anaerobic microflora.
Rice. 1. The mechanism of exacerbation of chronic odontogenic infection during obstruction of the outflow
tract
Another mechanism of imbalance between the chronic focus of odontogenic infection and the patient’s body
is associated with mechanical damage to the connective tissue capsule, which is accompanied by an increase
in its permeability. This can occur when a tooth is removed due to chronic periodontitis, or when there is
sudden excessive load on the tooth during eating.
15
Increasing the permeability of the connective tissue capsule also contributes to the fact that sensitized
lymphocytes - killers - penetrate into the infectious focus in greater numbers. As a result of the interaction of
such lymphocytes with the antigen, lymphocytes are released, which are endogenous factors of damage. The
development of exacerbation of chronic odontogenic infection may be associated with a change in the
functional state of immunological systems, a change in the immunological reactivity of the body, i.e., with a
change in the body’s ability to respond to an irritant, which is the infectious focus.
One-time injury
No.
Rice. 2. The mechanism of exacerbation of chronic odontogenic infection during simultaneous tooth trauma
The occurrence of acute odontogenic inflammatory diseases of the maxillofacial area is often preceded by the
impact on the patient’s body of various general factors: cooling, overheating, physical and emotional stress,
intercurrent diseases.
16
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Ceiicuataiimpommtm
kitt
Yaizhshyamt fmenty (fshtshry
strejatnt)
o-Tu
“fe + 0+o+o + e.
(ktrsh
otyaazhttyyuy ■ schucess
Rice. 3. The mechanism of exacerbation of chronic odontogenic infection under the influence of general
influences on the patient’s body
17
Osprsh azhshttelyty npvuecc
Rice. 4. The mechanism of exacerbation of chronic odontogenic infection under the influence of intercurrent
diseases
Exacerbation of chronic odontogenic infection can occur with functional insufficiency of the hypothalamuspituitary-adrenal cortex system, which normally controls the course of the inflammatory process and thereby
helps maintain balance between the focus of chronic odontogenic infection and the body.
Control questions
1.
List the ways of spread of odontogenic infection.
2.
Explain the mechanism of rapid development of the inflammatory process in the perimaxillary soft
tissues after an exacerbation of chronic odontogenic infection.
3.
List the reasons for the exacerbation of chronic odontogenic infection.
4.
Explain the mechanism of maintaining dynamic balance between the focus of chronic odontogenic
infection and the body.
18
Tests
1
The spread of odontogenic infection occurs
a)
by airborne dropletsc) by lymphogenous route
b)
contact d) hematogenous
2
The route of spread of odontogen is of greatest importance
no infection
a)
contactc) hematogenous
b)
lymphogenous
3.
Does the destruction of bone tissue predetermine the localization of ininfectious-inflammatory process?
a) yes b) no
4.
Specify the reasons for the exacerbation of chronic odontogenic in¬
infections
a)
obturation of the root canal
b)
violation of the integrity of the connective tissue capsule around
source of infection
c)
a) and b)
5.
Indicate possible reasons for the violation of the integrity of the connection
body-tissue capsule
a)
tooth removal) a) and b)
b)
excessive load on the tooth
6.
Changes in the body’s immunological reactivity can
lead to exacerbation of chronic odontogenic infection
a) yes b) no
7.
Hypothermia and overheating of the body can lead to
exacerbation of chronic odontogenic infection
a) yes b) no
8.
Are there humoral factors for maintaining balance?
between the focus of odontogenic infection and the body?
a) yes b) no
9.
Does sensitization of the body matter in the development of odontogenic inflammatory process?
a) yes b) no
10.
In the pathogenesis of the odontogenic inflammatory process there is
a)
immediate allergic reaction
b)
delayed allergic reaction
c)
the Arthus-Sakharov phenomenon
d)
cytotoxic reaction
Situational tasks
Task 1. After hypothermia, the patient experienced an exacerbation of chronic granulomatous periodontitis of
tooth 45. The next day, the patient developed a subperiosteal abscess of the lower jaw. Two days later, a
clinical picture of acute lymphadenitis of the neck developed.
Explain the mechanism of spread of odontogenic infection.
19
Task 2. A week after suffering a viral disease, the patient had the root of tooth 14 removed in the clinic
during sanitation of the oral cavity, after which inflammatory swelling appeared in the buccal area and severe
throbbing pain in the upper jaw area on the right.
!. What causes this course of the postoperative period?
2. Explain the mechanism of exacerbation of chronic odontogenic infection.
TOPIC 4. PERIODONTITIS. CLASSIFICATION. ACUTE PERIODONTITIS.
PATHOLOGICAL ANATOMY. CLINIC, DIAGNOSIS, TREATMENT
PLACE OF STUDY - DENTAL CLINIC. SURGICAL OFFICE.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the meaning of the terms “periodont” and “periodontitis”.
2.
Study the normal anatomy of the periodontium.
3.
Study the classification of periodontitis.
4.
Study the clinic and pathological anatomy of acute periodontitis.
5.
Master the methods of diagnosis and treatment of acute periodontitis.
The periodontium is a ligament that holds the tooth root in the bony alveolus. Its fibers in the form of thick
collagen bundles are woven into the cement at one end. Others - into the alveolar process, forming several
groups. Between the bundles of fibers there are gaps covered with loose fibrous connective tissue containing
vessels and nerve fibers; epithelial remains (islets) of Malasse are located here - the remains of the epithelial
root sheath and the epithelium of the dental plate.
Rice. 5. Main groups of periodontal fibers
VAG - alveolar ridge fibers; GV - horizontal fibers;
KB - oblique fibers; AB - apical fibers; MKV - interroot
fibers; TV - transseptal fibers; DDV - dentogingival fibers;
ADV - alveolar-gingival fibers
20
I
The periodontium performs the following functions:
1)
supporting;
2)
participation in tooth eruption;
3)
reflex;
4)
trophic;
5)
homeostatic;
6)
reparative;
7)
protective.
The structural components of periodontium are its cells and intercellular substance.
Periodontal cells are fibroblasts, osteoblasts, cementoblasts, osteoclasts and odontoclasts, macrophages. Mast
cells and leukocytes. Epithelial remains of Malasse.
The intercellular substance is formed by collagen and oxytalan fibers, forming a three-dimensional network,
and the main amorphous substance.
The periodontium is characterized by an intense blood supply. The main sources of its blood supply are the
superior and inferior alveolar arteries. Blood supply is also carried out by branches of the dental artery and
subperiosteal arteries. The vessels are oriented parallel to the long axis of the root. There are numerous
anastomoses between the arteries and veins in the periodontium.
Rice. 6. Blood supply
periodontal
A A - alveolar artery;
ZA - dental artery;
SPA - supraperiosteal
artery; MA - interdental
artery; D - gums
Fig.7. Innervation of the periodontium.
Different types of nerves
endings E - enamel; D - dentin;
D - pulp tooth; FOR -dental alveolus;PO - periodontium (according to T. Maeda et all., 1990,
from AR, Ten Cate, 1994, with modifications)
the endings are predominantly receptors.
The periodontium is innervated by both afferent and efferent fibers running as part of the superior and
inferior alveolar nerves. Nervous mechanoreceptors and pain
21
Periodontitis is an infectious and inflammatory process in the periodontium.
Classification of periodontitis
1.
With the flow
acute (serous, purulent);
chronic (fibrous, granulating, grayulomatous);
chronic in the acute stage.
2.
by localization
marginal;
apical.
3.
by prevalence
limited;
diffuse.
Acute periodontitis
Pathological anatomy. In the early stages of acute periodontitis, pathomorphological changes in the
periodontium are characterized by edema, hyperemia, serous exudation, which soon acquires a purulent
character. In the center of areas of leukocyte infiltration of the periodontium, there are foci of purulent
melting of necrotic tissue. Later, a shaft of granulation tissue is formed around such areas, i.e. A
microabscess is formed. In the bone tissue surrounding the periodontium, reactive inflammatory and
dystrophic changes occur, leading to lacunar resorption of the cortical plate of the alveoli. Edema and
infiltration of the alveolar walls by neutrophilic leukocytes of the bone marrow occur. No bone necrosis was
detected in periodontitis.
Clinical picture. With serous periodontitis, mild, dull, aching pain appears in the affected tooth, intensifying
at night. The pain does not radiate, the patient accurately points to the affected tooth. Then there is a feeling
as if a tooth is growing. There is slight mobility of the tooth and a pain reaction during vertical percussion.
With the transition of the process to the purulent stage, the intensity of pain increases. They become sharp,
pulsating, radiating to the temple, ear, eye, neck. The pain intensifies with physical stress, heat, in a
horizontal position. The affected tooth is loose, touching it causes sharp pain. The patient cannot close his
teeth. The gums in the tooth area are hyperemic and swollen. The periosteum of the alveolar process in the
area of the root apex is infiltrated. Palpation of the transitional fold and gums along the entire root becomes
painful. Regional lymph nodes are enlarged and painful.
Because of the pain, eating and sleeping are disrupted, and general weakness appears. Body temperature may
be low-grade. There may be a change in the blood picture in the form of leukocytosis, acceleration of ESR.
22
On radiographs in acute periodontitis, the periodontal fissure is not changed, destruction of the alveolar
bone tissue is not detected. EDI indicators are more than 100 μA.
Diagnosis of acute periodontitis is based on data from a clinical examination, radiography, radiovisiography
and EDI.
Treatment. When treating acute periodontitis, it is first necessary to create a free outflow of exudate from
the periapical area. This in most cases leads to the subsidence of the inflammatory process, prevents its
spread to surrounding tissues, reduces pain, and normalizes the general condition of the patient. If the
affected tooth is not severely damaged by the carious process and can be filled in the future, then drainage of
the inflammatory focus is carried out through the root canal.
In cases where it is not possible to drain an abscess in the periodontium through the root canal of a tooth due
to its obstruction, or the tooth is severely destroyed and its preservation is impractical, or the tooth is the
cause of a severe inflammatory process, they resort to tooth extraction surgery, the outflow of exudate occurs
through hole. If purulent periodontitis is accompanied by limited serous periostitis, dissection of the
infiltrated area of the mucous membrane and periosteum along the transitional fold of the affected tooth is
indicated. Therapeutic measures must be performed under local anesthesia.
According to indications, drug therapy (antibiotics, analgesics, anti-inflammatory drugs) and physiotherapy
(cold, solux, UHF, darsonvalization, diadynamic theca) are carried out. It is better not to use intense thermal
procedures, as they can cause the inflammatory process to spread to surrounding tissues.
With proper and timely treatment, the inflammatory process can be eliminated in most patients. After this, the
tooth is subjected to endodontic treatment and filling. The dead areas of the periodontium are restored or
replaced by fibrous tissue. If conservative treatment of acute periodontitis is not carried out or is carried out
insufficiently effectively, the inflammatory process in the periodontium takes a chronic course - chronic
periodontitis develops.
Control questions
1.
Define the terms “periodont” and “periodontitis”.
2.
Structure and functions of periodontium.
3.
Classification of periodontitis.
4.
Clinic and diagnosis of acute periodontitis.
5.
Treatment of acute periodontitis.
6.
Conduct a differential diagnosis of acute serous and purulent periodontitis.
7.
Indications for tooth extraction in acute periodontitis.
23
Tests
1.
Periodontitis - periodontal damage in the form
a)
degenerationc) proliferation
b)
inflammation
2.
Acute serous periodontitis is characterized by pain
a) constant
b) paroxysmal
3.
Tooth pain in acute periodontitis depends on
a)
the appearance of pus in the periodontium
b)
accumulation of pus in the periodotal fissure
c)
periodontal edema
4.
Acute purulent periodontitis is characterized by
a)
expansion of bone marrow spaces
b)
no changes in the bone tissue of the jaw
5.
In acute periodontitis, there is blood in the bone tissue of the jaw
veins
a)
expanded
b)
thrombosed
6.
In acute purulent periodontitis, the periosteum of the jaw changes
nena from the side
a)
vestibular or oral
b)
oral and vestibular
7.
In acute purulent periodontitis, pathological changes
gums presented
a)
infiltrate and hyperemia
b)
hyperemia and edema
c)
fistulas
d)
pale pink mucous membrane
8.
In acute apical periodontitis, tooth mobility is
consequence
a)
pulp necrosis
b)
periodontal inflammation
9.
The patient was admitted with complaints of newly emerging
There is pain in tooth 46, which intensifies when eating. Opening the mouth
free, the mucous membrane around this tooth is pale pink, painless
flattened. The crown of tooth 46 is affected by caries; when probing the deep
no pain was detected on the side of the carious cavity; percussion of the tooth was slightly painful
Nenna. A preliminary diagnosis has been established
a)
pulpitis
b)
acute periodontitis
c)
chronic periodontitis
10.
Periodontitis and periostitis are distinguished by
a)
percussion pain in the “causal” tooth
b)
percussion pain in the teeth adjacent to the “causative” one
24
c)
inflammatory changes in the gums on one side of the alveoli
d)
swelling of the soft tissues of the face
Situational tasks
Task 1. Patient L., 34 years old, went to the dental clinic with complaints of severe throbbing pain in the area
of tooth 34 and general weakness. Sick for three days. Objectively: there is a carious cavity on the chewing
surface of tooth 34, probing is painless, percussion is sharply positive, the gums are swollen and hyperemic.
1.
Make a preliminary diagnosis.
2.
Make a plan for examination and treatment.
Task 2. Patient S, 40 years old, complains of sharp, constant pain in the area of tooth 11, which radiates to the
eye and temple. The use of cold slightly reduces the intensity of pain, heat intensifies it. There is a feeling of
a “grown” tooth. Objectively: on the lingual surface of the tooth crown! 1 there is a deep carious cavity,
vertical and horizontal percussion is sharply painful. No changes are detected on the x-ray of the alveolar
process.
1.
Make a diagnosis.
2.
What additional data is needed to clarify the diagnosis?
3.
Make a treatment plan.
TOPIC 5. CHRONIC PERIODONTITIS. CLINIC, DIAGNOSIS, DIFFERENTIAL
DIAGNOSIS, TREATMENT
PLACE OF STUDY - DENTAL CLINIC. SURGICAL OFFICE.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the clinic and pathological anatomy of chronic periodontitis.
2.
Master the methods of diagnosis and treatment of chronic periodontitis.
3.
Learn to carry out differential diagnosis of various forms of chronic periodontitis.
Chronic periodontitis has a tendency towards proliferative processes. Pathologically, they are divided into
fibrous, granulating and granulomatous. According to the nature of the course and the pathological picture,
chronic periodontitis occurs in two forms - active and stabilized. The active form of chronic periodontitis is
accompanied by
25
is caused by the formation of granulations, fistulous tracts, granulomas, and the occurrence of suppuration in
the perimaxillary tissues. The stabilized form includes fibrous periodontitis, in which periodontal tissue is
replaced by coarse fibrous connective tissue.
Fibrous periodontitis is characterized by an asymptomatic course. Complaints of pain appear only when the
inflammatory process worsens. The radiograph shows the deformation of the periodontal fissure, in the form
of its expansion. Due to the developed hypercementosis, some of its areas may be narrowed.
Granulating periodontitis is characterized by an active course. The growing granulation tissue in the area of
the root apex spreads to the adjacent sections of the periodontium and the alveolar wall, causing lacunar
resorption of the bone substance with the participation of osteoclasts. As a result of the formation of a hole in
the cortical plate of the alveoli or the body of the jaw, granulation tissue penetrates into the soft tissues, and
fistulas occur. Excessive spread of granulations into the maxillary tissue leads to the formation of
subcutaneous granuloma.
The gums in the area of the apex of the tooth root are hyperemic and swollen. Percussion of a tooth in a
vertical direction causes pain. Granulating periodontitis is characterized by the formation of a fistulous tract
in the area of the vestibule of the mouth or the skin of the face and neck. The location of the fistula usually
corresponds to the location of the affected tooth.
Discharge from fistulous tracts is most often scanty, serous-purulent or bloody-purulent. Granulations may
bulge from the mouth of the fistula tract, or it may be covered with a blood crust. In the presence of a
functioning fistula, exacerbations rarely occur. X-ray reveals a focus of bone tissue destruction of irregular
shape, with uneven edges, without clear boundaries, adjacent to the apex of the tooth root.
Granulomatous periodontitis, unlike granulating periodontitis, is less active. The growths of granulation
tissue in the area of the apex of the tooth root are surrounded by a fibrous capsule.
Depending on the structure, granulomas are distinguished:
1)
simple, consisting of granulation tissue;
2)
epithelial, which, along with granulation tissue, contain epithelial strands;
3)
racemose, containing cavities lined with epithelium.
Depending on the size there are:
1)
granulomas (up to 0.5 cm in diameter);
2)
cystogranulomas (0.6-0.9 cm);
3)
radicular cysts (1 cm or more).
26
Granulomas have the ability to grow. As a result of the restructuring of bone tissue in the area of the alveolar
process along the projection of the apex of the tooth root, a limited protrusion of bone tissue appears. On an
x-ray, a rounded focus of destruction with smooth edges and clear boundaries, often limited to a narrow zone
of osteosclerosis, is determined in the periapical tissues.
Rice. 8. X-ray picture of chronic periodontitis (scheme) a-granulating; b - granulomatous; c - fibrous
Aggravated chronic periodontitis, in contrast to acute periodontitis, is characterized by the above X-ray
picture and data from the medical history.
Treatment of chronic periodontitis is usually conservative. If conservative treatment is ineffective, surgical
treatment is performed.
Control questions
1.
What forms of chronic periodontitis are distinguished?
2.
Clinic of chronic periodontitis.
3.
Pathological picture of chronic periodontitis.
4.
What types of granulomas are distinguished depending on the pathological picture and size?
5.
Explain the mechanism of formation of subcutaneous granulomas in chronic granulating
periodontitis.
27
Topic 6. Surgical methods for the treatment of chronic periodontitis
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min. Purpose of the lesson
1.
Study surgical methods for treating chronic periodontitis.
2.
Study the indications and contraindications for surgical treatment of chronic periodontitis.
Surgical treatment of chronic periodontitis is used for pathological processes in teeth and periodontal tissues
that are not subject to or cannot be treated conservatively.
Surgical treatment methods, in addition to tooth extraction, include tooth-preserving operations such as:
1)
resection of the root apex;
2)
hemisection of the tooth:
3)
root amputation;
4)
coronoradicular separation;
5)
dental replantation;
6)
compactosteotomy and curettage.
Indications for surgical treatment of chronic periodontitis are:
1)
acute odontogenic diseases of the maxillofacial region;
2)
frequent exacerbations of the inflammatory process in the periodontium, despite the full treatment;
3)
absence of signs of tissue regeneration in the lesion 6-8 months after the treatment and high-quality
obturation of the root canals;
4)
significant resorption of periodontal bone tissue with existing deep bone pockets communicating
with the periapical focus;
5)
the presence of channels that are difficult to access for processing;
6)
chronic odontogenic sepsis;
7)
chronic odontogenic intoxication of the body.
Contraindications to tooth-preserving operations are:
are:
1)
stage of exacerbation of the periapical inflammatory focus;
2)
inflammatory periodontal diseases in the acute stage;
3)
inflammatory diseases of the oral mucosa;
4)
acute infectious diseases;
5)
chronic diseases of internal organs in the acute stage, etc.
thirty
Treatment using surgical methods is carried out in 4 stages:
1.
Endodontic treatment of patent tooth canals (mandatory stage d is carried out before surgery on the
same day; if there is a fistula, it can be done the day before surgery).
2.
Surgical intervention.
3.
Temporary stabilization of teeth or remaining segments. It is a measure to prevent secondary
occlusal injury. Performed after surgery (used according to indications).
4.
Orthopedic treatment. As a rule, it is performed after hemisection, amputation and coronoradicular
separation.
Coronoradicular separation is dissection of the lower molar in the bifurcation area, followed by curettage of
the interroot area and orthopedic treatment.
It is used for localization of the inflammatory process in the area of the interradicular septum and for
perforation of the bottom of the tooth cavity.
A contraindication is a significant loss of the interradicular septum, leading to functional inferiority of the
remaining tooth fragments.
Compactosteotomy with subsequent curettage of periapical tissues is the creation of a perforation hole in the
bone at the level of the projection of the root apex, through which curettage of the periapical inflammation is
carried out, followed by washing it with antiseptic solutions.
It is used if there are contraindications to resection of the root apex (possibility of tooth loosening and loss
after resection of the root apex).
Control questions
1.
List the tooth-preserving operations used in the treatment of chronic periodontitis.
2.
List the indications and contraindications for surgical treatment of chronic periodontitis.
3.
What stages does the treatment of chronic periodontitis include using tooth-preserving operations?
4.
Describe operations such as coronoradicular separation and compactosteotomy followed by
curettage.
31
1.
What preoperative preparation is necessary?
2.
What treatment will be given after the operation?
Task 2. The patient has chronic granulomatous periodontitis of the first upper incisor on the right.
Conservative treatment was carried out. On the control radiograph after 1 year there are no signs of a
decrease in the focus of bone tissue rarefaction.
Make a plan for further treatment.
Topic 7. Resection of the root apex, hemisection, root amputation
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min.
Purpose of the lesson
1.
Study the indications and contraindications for resection of the root apex, hemisection, and root
amputation.
2.
Master the technique of performing tooth-preserving operations.
Resection of the apex of the corpus
The operation is performed on single-rooted teeth, less often on small and large molars, which is explained
by the difficulty of access, the traumatic nature of the operation, as well as the risk of damage to the
maxillary sinus and the contents of the mandibular canal.
Indications
1)
the inability to eliminate the chronic inflammatory process in the periodontium using conservative
methods;
2)
perihilar cyst;
3)
fracture of the root apex;
4)
lateral perforation of the root at the apex;
5)
excessive removal of filling material beyond the apex with the development of pain;
6)
absence of regression of the perihilar pathological focus;
7)
the presence of a fistula tract after correctly performed endodontic treatment.
Contraindications!) Tooth mobility;
2)
exacerbation of the inflammatory process;
3)
pathological conditions of the periodontium;
34
4)
the spread of the inflammatory process to a significant part of the periodontium, as a result of which
it would be necessary to resect a large part of the tooth root;
5)
spread of the carious process to the root of the tooth;
6)
functional inferiority of the tooth;
7)
exposure of the tooth root by half or more.
Progress of the operation
The operation is performed under local anesthesia. An incision is made to form an oval or trapezoidal
mucoperiosteal flap. The base of the flap should face the transitional fold, which ensures the viability of the
flap. The top of the cut should be at the level of the middle of the root. The flap thus covers the resulting bone
defect. The flap is separated from the bone using a rasp. The outer cortical plate of the alveolar process is
trepanned along the projection of the root apex. The root apex is resected with a bur, granulations are scraped
out, and the edges of the bone cavity are smoothed. If necessary, retrograde root filling with amalgam is
performed. The level of the root resection line should coincide with the level of the bottom of the bone
cavity. The resulting bone wound is washed with antiseptics, the bone cavity is filled with a hemostatic
sponge, hydroxyapatite, antibiotics, or left under a blood clot. The flap is placed in place and secured with
sutures. A pressure bandage is applied externally and cold is prescribed.
Rice. 9. Scheme of the canine root apex resection operation
a- arcuate incision; b-trephination of the outer wall of the hole with a grooved
chisel; c - cutting off the root apex with a fissure bur; g- fixation
mucoperiosteal flap placed in place with interrupted sutures
35
Tooth hemisection - removal of the tooth root with the adjacent crown part of the tooth.
The operation is performed on large molars of the lower jaw. Indications
1)
deep intraosseous pockets in the area of one of the roots;
2)
pathological process in the periodontium in the area of one molar root;
3)
perforation in the area of root bifurcation;
4)
perforation of one of the roots;
5)
caries of part of the tooth crown with the process spreading to one of the roots;
6)
fracture of one of the roots of a molar;
7)
pathological process in the area of the apex of the interradicular septum.
Contraindications
1)
tooth mobility;
2)
destruction of the tooth crown by the carious process;
3)
pathological process in the area of both roots;
4)
complete destruction of the interroot septum;
5)
exposure of roots by half or more;
6)
the presence of fused roots;
7)
the presence of impassable channels in the roots that must be preserved;
8)
pronounced hypercementosis of the removed root. Progress of the operation
The crown of the tooth is cut into two halves using a bur. The root, together with the adjacent part of the root,
is removed with forceps or an elevator. The interradicular septum and bone tissue surrounding the remaining
segment of the tooth are preserved. After treating the bone wound, sutures are placed on the edges of the
socket. The sharp edges of the preserved part of the crown are smoothed.
Root amputation - removal of the root of a tooth to its origin, i.e. bifurcations.
Amputation is used on multi-rooted teeth of the upper and lower jaw.
Indications and contraindications are the same as for hemisection.
Progress of the operation
The mucoperiosteal flap is peeled off. The corresponding bone wall of the alveoli is excised. The root is cut
with a bur at its base and removed with an elevator. Sharp bone edges are smoothed. The wounds are treated
with antiseptics and sutured.
36
Rice. 10. Scheme of hemisection and amputation of the root; hemisection of the lower molar; b- amputation
of the root of the upper molar
In the postoperative period, cold is used locally, treatment of the oral cavity with antiseptics, analgesics,
antibiotics, and physiotherapy according to indications.
Complications. During these operations, complications such as:
1)
damage to the alveolar nerves and blood vessels;
2)
perforation of the maxillary sinus and nasal cavity;
3)
damage to the mandibular canal.
Prevention of complications consists of a thorough examination of the patient and careful performance of
surgical intervention.
Control questions
1.
List the indications and contraindications for resection of the root apex.
2.
List the indications and contraindications for hemisection and root amputation.
3.
Describe the course of the operation during resection of the equine apex.
4.
Describe the course of the operation during hemisection and root amputation.
5.
List the main complications during the above tooth-preserving operations.
Tests
1. Specify tooth-preserving operations performed on single-rooted teeth
a)
resection of the root apex
b)
hemisection
c)
root amputation
37
2.
Hemisection is performed on multi-rooted teeth
a) upper jaw
b) lower jaw
3.
Pathological mobility of the tooth is for resection of ver¬
hushki tooth
a)
indication
b)
contraindication
4.
A radicular cyst of the jaw is a) an indication for resection of the tooth apex b) a contraindication
5.
List the indications for resection of the tooth apex
a)
fracture of the root apex
b)
chronic granulomatous periodontitis, not subject to treatment
conservative treatment
c)
exposure of the tooth root on 'A'
6.
Fused tooth roots are suitable for hemisection
a) indication
b) contraindication
7.
Complete destruction of the interroot septum is for
missections
a) indication
b) contraindication
8.
Perforation of the bottom of the tooth cavity is a) an indication for hemisection b) a contraindication
9.
Amputation is performed more often
a) palatal root b) buccal roots
10.
Filling the root canal of a tooth during tooth extraction
storage operation is mandatory
a)
yes
b)
no
Situational tasks
Task 1. The patient is diagnosed with periodontitis of the lower sixth tooth. During treatment, perforation of
the tooth cavity occurred. The radiograph revealed resorption at the apex of the distal tooth root.
1.
List treatment options.
2.
Describe the surgical technique.
Task 2. The patient complained of periodically occurring swelling in the area of tooth 22. Locally: slight pain
upon percussion of the tooth, deep carious cavity, the tooth does not respond to EDI. On the x-ray, the root
canal is not sealed, in the area of the apex there is a rarefaction of bone tissue with clear boundaries and a
round shape.
1.
Make a diagnosis.
2.
What operation is indicated in this case and what is the technique for performing it?
3.
What preparatory measures need to be taken before the operation?
38
TOPIC 8. DENTAL REPLANTATION AND IMPLANTATION SURGERY. INDICATIONS
AND CONTRAINDICATIONS. PREPARATION AND STAGES OF SURGERY,
COMPLICATIONS
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the meaning of the terms “replantation” and “implantation”.
2.
Study the indications and contraindications for replantation and implantation.
3.
To study the features of preoperative preparation and management of the postoperative period.
4.
Master the technique of tooth replantation.
Replantation is the transplantation of an extracted tooth into its own socket. Replantation of both singlerooted and multi-rooted teeth is performed. Indications
1)
failure of conservative treatment of teeth affected by periodontitis;
2)
accidental tooth extraction;
3)
traumatic complete dislocation of the tooth.
Contraindications
1)
functional inferiority of the tooth;
2)
periodontal diseases;
3)
violation of the integrity of the walls of the tooth socket;
4)
acute stage of inflammation in the periodontium;
5)
unfavorable anatomical and topographic conditions for tooth extraction;
6)
damage to the root during processing;
7)
the impossibility of inserting a tooth into the hole with sharply diverging roots. Preparation for
replantation
Preparation for replantation begins with sanitation of the oral cavity. Dental plaque is removed from the tooth
being replanted. The carious cavity is treated. The tooth canals are treated and filled. The canals of a tooth
can be filled even after it has been removed.
After the onset of anesthesia, the circular ligament of the tooth is carefully peeled off and the tooth is
removed. The extracted tooth is placed in an isotonic solution, sodium hypochlorite solution. Granulations
are scraped out from the bottom of the hole, and a tampon is loosely inserted. Resection of the root apex is
performed. The tooth is replanted using the forceps used to remove it. Gauze swabs are placed on the tooth,
after which the patient closes his jaw tightly for 10-15 minutes. After removing the tampons, the tooth is
fixed using plastic or wire splints or using composite materials. It is possible to carry out delayed replantation
(up to 1 week), when for some reason we were unable to replant the tooth on the first day.
39
There are three types of engraftment of a replanted tooth with an alveolus:
1)
periodontal - with complete preservation of the periodontium and periosteum of the alveoli (the most
favorable);
2)
periodontal fibrous - with partial preservation of the periodontium and periosteum of the alveoli;
3)
osteoid - with complete destruction of the alveolar periosteum and periodontal fibers (least
favorable).
The tooth is excluded from the bite for the entire period of its fusion with the socket (4-6 weeks).
Immobilization is maintained at the same time. A mechanically gentle diet is prescribed. Careful oral hygiene
is mandatory.
Dental implantation is an operation in which an implant made of metal or biomaterials is inserted into the
socket or jaw bone. Implants are used to fix crowns, bridges or removable dentures.
Indications: included and end defects of the dentition.
Contraindications
1.
Local:
1)
periodontal diseases;
2)
diseases of the oral mucosa;
3)
neoplasms of the jaws;
4)
unfavorable anatomical and topographic conditions (proximity of the maxillary sinus, mandibular
canal);
5)
dystrophic changes in the bone tissue of the jaws.
2.
General:
1)
endocrine diseases;
2)
diseases of the hematopoietic system;
3)
collagenosis;
4)
malignant neoplasms;
5)
specific diseases;
6)
long-term chronic diseases of internal organs;
7)
diseases of the immune system.
The success of the operation depends on strict adherence to contraindications.
Implants inserted into the bone can be: cylindrical, helical, flat; whole and composite.
Implantation can be direct, when immediately after tooth extraction the socket is adapted and an implant is
inserted into it, or indirect, when the operation is performed after the socket has healed.
The surgical technique is that after anesthesia, an incision is made along the crest of the alveolar process, a
hole is drilled in the bone into which the implant is inserted. The wound is sutured.
Implantation can be one-stage, when there is communication between the bone wound and the implant and
the oral cavity, and two-stage, when at the first stage the intra-alveolar part of the implant is inserted into the
bone and the wound is sutured tightly, iol.
40
completely isolating the implant from the oral cavity. After the implant has been implanted, a mucosal
incision is made above it and connected to the extra-alveolar part, which will communicate with the oral
cavity. With two-stage implantation, more favorable conditions are created for implant healing, since there is
no communication between the implant bed and the oral cavity.
The denture is fixed on a flat implant for 3-4 months, on a screw implant - for 4-6 months.
Complications during implantation can be varied, the most unfavorable of which is implant rejection due to
biological incompatibility or the development of inflammatory phenomena.
Prevention of complications consists of strict adherence to contraindications to implantation, surgical
techniques and oral hygiene.
If the outcome is successful, the average lifespan of the implant is about 5-8 years.
Control questions
1.
What are replantation and implantation?
2.
List the indications and contraindications for tooth replantation.
3.
What is the preparation for tooth replantation?
4.
Describe the progress of the tooth replantation surgery.
5.
How and in what time frame does the engraftment of the tooth and socket occur during tooth
replantation?
6.
List the indications and contraindications for dental implantation.
7.
Describe the progress of dental implant surgery.
8.
List the main complications of replantation and implantation.
Tests
1.
Replantation is
-.■ a) insertion of a tooth into its own socket b) insertion of a tooth into the socket of another missing tooth
2.
Complete tooth dislocation is for replantation
a) indication
b) contraindication
3.
Violation of the integrity of the walls of the hole is an indication for
replantation
a) yes b) no
4.
Acute inflammatory process is a contraindication
for replantation
a) yes b) no
5.
Before tooth replantation, it is necessary to
root apex resection
a) yes b) no
41
6.
Immobilization of the replanted tooth is carried out for a period of time
a) 1-2 weeks
b) 3-4 weeks) 4-6 weeks
7.
The most optimal type of socket fusion and replantation
bathroom tooth is
a)
periodontal
b)
periodontal fibrous
c)
osteoid
8.
The least optimal type of socket fusion and replantation
bathroom tooth is
a)
periodontal
b)
periodontal fibrous
c)
osteoid
9.
The introduction of foreign material into the jaw bone is called
a)
replantation
b)
implantation
c) autotransplantation
10.
Dental implantation is performed
a)
in one stage
b)
in two stages
c)
a) and b).
Situational tasks
Task 1. During a fall, the patient had a complete dislocation of the central upper incisors. The time from the
moment of injury is 6 hours.
1.
Make a treatment plan.
2.
What is the preoperative preparation?
Task 2. During the removal of the lower canine on the left, an accidental extraction of the intact lower first
premolar on the left occurred. Your tactics.
TOPIC 9. ACUTE ODONTOGENIC PERIOSTITIS OF THE JAWS. PATHOLOGICAL
ANATOMY. CLINIC, DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, TREATMENT
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the clinical picture and diagnosis of acute odontogenic periostitis of the jaws.
2.
Study the pathological anatomy of acute periostitis of the jaws.
42
3.
Learn to carry out differential diagnosis in acute odontogenic periostitis of the jaws.
4.
Master the methods of conservative and surgical treatment of acute periostitis of the jaws.
Acute odontogenic periostitis of the jaws is an acute infectious-inflammatory disease of the periosteum of the
jaws, occurring as a complication of diseases of the teeth and periodontal tissues. Classification of periostitis
of the jaws
1.
Acute-serous, purulent;
2.
Chronic (ossifying).
Periostitis most often develops as a result of exacerbation of the chronic inflammatory process in the
periodontium. Much less frequently, periostitis of the jaw occurs as a complication of acute purulent apical
and marginal periodontitis.
The periosteum of the jaw may be involved in the process due to its spread from the tissues surrounding the
impacted tooth or hard odontoma. Infection of the contents of jaw cysts can also lead to the development of
periostitis.
Periostitis of the jaws can develop as a complication of conservative dental treatment or after tooth
extraction.
Different teeth are not equally often the source of infection, as a result of which periostitis of the jaw
develops.
Rice. 11. Incidence (%) of acute periostitis of the jaws
depending on the tooth—the source of infection Solid line—lower teeth; dotted - upper.
"
Pathological anatomy. Acute periostitis occurs in the form of limited inflammation of the periosteum of the
alveolar cane over several teeth. The process rarely extends to the periosteum of the jaw body.
In the initial period of the disease, the periosteum is thickened, swollen, and infiltrated with leukocytes. In the
vessels there is plethora, stasis, and bleeding into the soft tissues. The accumulation of serous-purulent
exudate can cause detachment of the periosteum. Gradually, the number of cellular elements in the exudate
increases, and it acquires a purulent character. In the center of the infiltrate, necrosis with purulent melting
occurs. This is accompanied by a violation of the integrity of the periosteum and the spread of the
inflammatory process into the surrounding tissues.
Osteoclastic resorption of the cortical plate is noted. Resorbed bone is replaced by cellular fibrous tissue.
Detachment of the periosteum can cause disruption of the extraosseous blood supply to the jaw and lead to
secondary cortical osteomyelitis.
In parallel with bone tissue resorption, reparative processes occur, which in some cases can be so intense that
they can lead to jaw deformation. These pathomorphological changes are characteristic of chronic periostitis
of the jaw.
The clinical picture is varied. It depends on the reactivity of the patient’s body, the type of inflammatory
reaction, the virulence of the infection and the localization of the inflammatory process. The typical clinical
picture usually develops within 1-2 days. During this period, health deteriorates, weakness occurs, and body
temperature rises. A headache appears, appetite disappears, and sleep is disturbed.
Pain in the area of the causative tooth moves to the corresponding half of the jaw. They radiate to the temple,
ear, eye, neck.
With the development of the inflammatory process in the periosteum, swelling of the peri-maxillary tissues
appears, which changes the configuration of the face. The localization of edema is quite typical and depends
mainly on the location of the causative tooth. The color of the skin is usually not changed; it may form a fold.
Upon palpation, a dense and painful infiltrate is determined according to the location of the subperiosteal
inflammatory focus.
When the process is localized in the area of large molars of the lower jaw due to the development of
inflammatory contracture of the masticatory muscles, opening the mouth can be painful and limited.
Characteristic changes in the oral cavity. Hyperemia and swelling of the mucous membrane of the transitional
fold appear over several teeth. At the initial stage of development of the process, the transition fold is
smoothed out. When the process transitions to a purulent form and exudate accumulates under the periosteum
along the transitional fold, a roller-like protrusion begins to form - a subperiosteal abscess. Fluctuation may
be detected. When pus spreads under the mucous membrane, a subcessal abscess is formed.
44
When examining the oral cavity, the causative tooth is discovered. Percussion of the tooth is not pronounced
or absent. Percussion of adjacent teeth is painless.
An x-ray of the alveolar process and the body of the jaw does not reveal changes characteristic of acute
periostitis.
The body temperature during periostitis is subfebrile. Blood tests determine leukocytosis and accelerated
ESR.
Local manifestations of the disease have some features depending on the localization of the process.
Periostitis most often occurs on the vestibular side of the alveolar process, much less often on the lingual and
palatal side. This is explained by the anatomical structure of the jaws (the outer bone wall of the alveoli is
thinner), the direction of blood and lymph flow.
When the process is localized on the vestibular side, swelling of the lips, cheeks, infraorbital areas, and
eyelids is noted.
Acute purulent periostitis of the upper jaw on the palatal side most often occurs as a result of the spread of
infection from the lateral incisor, the first large and small molars.
Periostitis on the palatal side (palatal abscess) is characterized by a peculiar course. From the very beginning,
strong aching, then pulsating pain appears in the area of the hard palate. The mucous membrane above the
source of inflammation turns red. Due to the absence of a submucosal layer, the swelling is mild.
Rice. 12. Palatal abscess and incision line during its opening
As a result of a progressive increase in the amount of purulent exudate, a swelling is formed under the
periosteum of the hard palate, sharply delimited from the surrounding tissues and having a semicircular
shape, in the center of which
45
fluctuation is determined. Eating and speaking are difficult. When the process is localized at the border of the
hard and soft palate, pain appears when swallowing.
With periostitis of the lower jaw, hyperemia and swelling of the mucous membrane in the alveolar process
and sublingual region appear on the lingual side. The hyoid ridge enlarges and bulges. The tongue rises and
moves in the opposite direction. The infiltrate is located within the alveolar process at the border with the
sublingual region. Movement of the tongue is difficult, pain occurs when swallowing and opening the mouth.
Diagnosis of acute periostitis of the jaws is based on clinical and laboratory examination data.
Differential diagnosis. Acute purulent periostitis of the jaw should be differentiated from acute periodontitis,
osteomyelitis, abscess and phlegmon, lymphadenitis and other acute inflammatory diseases of the
maxillofacial region.
To carry out an accurate differential diagnosis, knowledge of the clinic of these diseases is necessary.
Periostitis differs from these inflammatory processes primarily in the localization of the infiltrate. With
periostitis, it is located in the area of the alveolar process on one side over several teeth (for the differential
diagnosis of periostitis with acute periodontitis and acute osteomyelitis of the jaws, see Lesson 16).
Treatment. Treatment of patients with acute periostitis of the jaws is based on complex therapy, when timely
surgical intervention is combined with medication and physical treatment.
The main therapeutic measures for acute periostitis consist of promptly opening the inflammatory focus and
creating a free outflow of the resulting exudate. The absence of fluctuation is not a contraindication to
surgical treatment.
Surgery is performed under local anesthesia, anesthesia according to indications. For periostitis, an incision is
made along the transitional fold of the jaw, with obligatory dissection of the periosteum, along the entire
length of the infiltrate. Drainage is inserted into the wound.
When opening a palatal abscess, a small area of soft tissue is excised from the abscess wall (triangular or
oval), which ensures good drainage.
Before opening the subperiosteal abscess, the causative tooth is removed (if possible), if its preservation is
impractical. In other cases, the tooth is preserved. It is advisable to open the tooth canals to drain the
periodontal space before making the incision. Treatment of the tooth is completed after acute inflammatory
phenomena have subsided.
Conservative treatment consists of antibacterial and anti-inflammatory therapy, physiotherapy (cold, UHF,
fluorination, laser therapy). The oral cavity is treated locally with antiseptic solutions.
46
Conservative therapy should not replace mandatory surgical intervention!
As a result of treatment, the inflammatory process quickly stops. A thin scar forms at the site of the former
incision along the transitional fold. Residual effects in the form of compaction and mild pain can persist for
2-3 weeks.
Control questions
1.
Define acute odontogenic periostitis of the jaws.
2.
Specify the reasons for the development of acute periostitis of the jaws.
3.
On what conditions does the clinical picture of acute periostitis of the jaws depend?
4.
What is the diagnosis of acute periostitis of the jaws based on?
5.
What diseases need to be differentiated from acute odontogenic periostitis of the jaws?
6.
What is the treatment of acute odontogenic periostitis of the jaws?
Tests
1.
A patient with acute periostitis of the jaw has pain in a) several teethb) one tooth when chewing
2.
Acute periostitis is characterized by pain in
a)
“causal” teeth) area of the jaw
b)
half of the jaw) several teeth
3.
In case of acute purulent periostitis of the jaw, microscopically
purulent impregnation is revealed
a)
endostav) bone marrow
b)
periosteum
4.
In acute periostitis of the jaw, bone marrow is characterized by
a)
thrombosis and infiltration of blood vessels
b)
infiltration and osteoclastic resorption of bone beams
5.
I was sick for about a week when, after cooling, pain appeared in the
filled tooth 24. During external examination there are no deviations from the norm
revealed. Mouth opening is free. Speech with a lisp. Mucous
the membrane of the vestibule of the mouth is pale pink. Tooth 24 responds to percussion.
There is a painful spherical bulge on the hard palate on the left
with clear boundaries, about 2.5 cm in diameter, covered with hyperemic
new mucous membrane. A preliminary diagnosis has been established
a)
exacerbation of chronic periodontitis
b)
neoplasm of the hard palate
47
c)
d)
e)
6.
a)
acute purulent periostitis of the upper jaw
acute osteomyelitis of the upper jaw
secondary osteomyelitis of the upper jaw
Acute periostitis is characterized by pain
only in teeth) in several teeth
b)
in the tooth at night d) in the jaw
7.
Restriction in mouth opening is observed during acute periods
stitis of the lower jaw in the area
a)
premolarsc) frontal teeth
b)
molars
8.
The patient has acute purulent periostitis of the upper jaw. Doctor
opened the cavity of the “causal” fang, expanded the root canal, from which
pus came out, scheduled the patient for the next day. Doctor's tactics
a) correct
b) incorrect
9.
The most effective treatment for odontogenic abscess of the hard palate
a)
dissection through the entire thickness of the mucous membrane
b)
excision of the entire thickness of the mucous membrane and periosteum
c)
dissection of the mucous membrane to the bone from right to left
d)
removal of the “causal” tooth
e)
removal of the “causal” tooth and dissection of the mucous membrane
10.
In acute purulent periostitis, bone marrow spaces
jaws infiltrated with leukocytes
a) true b) false
Situational tasks
Task 1. For an abscess of the hard palate to the right of tooth 12, the dentist removed the causative tooth,
opened the abscess with a linear incision, drained the wound, prescribed anti-inflammatory therapy and a
return visit after 3 days.
What mistakes did the doctor make in treating the patient?
Task 2. The patient complains of pain in the left lower jaw, difficulty opening the mouth, and increased body
temperature. Locally: swelling of the tissues of the parotid-masticatory area on the left, limitation of mouth
opening to 2 cm, infiltration of the transitional fold of the lower jaw on the left along the large molars, the
crown of tooth 47 is destroyed.
1.
Make a diagnosis.
2.
Make a treatment plan.
TOPIC 10. TEETHING DISEASES. CAUSES. CLINIC, DIAGNOSTICS, TREATMENT
PLACE OF STUDY - DENTAL CLINIC. SURGICAL OFFICE.
Lesson duration - 180 min. Purpose of the lesson
1.
Study the classification of teething diseases.
2.
Study the causes of teething diseases.
3.
Study the clinic and methods for diagnosing teething diseases.
4.
Master the methods of treating teething diseases.
Classification of teething diseases
1.
Tooth dystopia - incorrect position of the tooth:
a)
the tooth is located in the dental arch, but the longitudinal axis of the tooth is deviated in
oral or vestibular side;
b)
the tooth is located within the alveolar process, but outside the dental arch;
c)
the tooth is located outside the alveolar process (in the body or branch of the lower
her jaw, in the maxillary sinus).
2.
Tooth retention - disruption of the process of tooth eruption:
a)
incomplete retention - incomplete eruption of the tooth through the bone
tissue or mucous membrane;
b)
complete retention - delayed eruption is fully formed
of the tooth through the compact plate of the jaw.
3.
Difficulty in tooth eruption.
The most common diseases observed are the eruption of the lower and upper wisdom teeth, the upper canine,
the upper and lower premolars, and the lower incisors.
The causes of teething diseases can be divided into 2 groups:
1.
General - diseases of the mother during pregnancy (viral etiology, poisoning, severe intoxication,
etc.), general infectious, endocrine diseases of the child after birth, etc.
2.
Local - injuries (including operating room), inflammatory diseases, tumors of the jaws, bad habits.
Dystopia of the tooth. Occurs as a result of a violation of the sequence and timing of teething. As mentioned
above, there are 3 forms of dystopia. An incorrectly positioned tooth can cause changes in the position of
neighboring teeth and antagonist teeth, which leads to malocclusion and functional and aesthetic changes. A
dystopic tooth can injure the mucous membrane of the cheek and tongue, causing erosions and ulcers.
Incomplete tooth retention is clinically characterized by the appearance of part of the crown in any part of the
alveolar process of the jaw. 3 as a result of permanent injury to the mucous membrane adjacent to the
eruption
49
of the tooth crown, inflammation occurs around it. Sometimes there is an asymptomatic course. The
examination reveals a thickening of the alveolar process, covered with a hyperemic mucous membrane.
An x-ray reveals a tooth located in the alveolar process of the jaw. Part of the crown is covered with bone
tissue. A semi-impacted tooth can often be displaced.
Complete tooth retention is usually characterized by an asymptomatic course. Often such a tooth is
discovered by chance during radiography. Retention is indicated by the absence of one of the teeth in the
dental arch. In its place there may be a baby tooth. Sometimes an impacted tooth forms a protrusion of the
outer wall of the alveolar process. In this case, you can palpate the contours of the tooth. Impacted teeth can
lead to displacement of neighboring teeth, compress nerve fibers and cause pain such as neuralgia or neuritis,
paresthesia. An impacted tooth is often the source of an inflammatory process.
1 *L SCHLSH W
Rice. 13. Retention and semi-retention of teeth
Diagnosis of teething diseases is based on clinical and x-ray examination data.
Treatment. In case of dystopia and incomplete tooth retention, orthodontic treatment is possible. Elimination
of trauma to the mucous membrane in dystopia is sometimes possible by grinding off the cusps or cutting
part of the tooth crown. When orthodontic treatment is not indicated or does not produce results, teeth must
be removed.
50
In case of complete tooth retention and dystopia with the tooth located outside the alveolar process with an
asymptomatic course of the disease, treatment is not indicated. Dynamic observation is carried out.
Indications for the removal of such teeth are:
1.
Inflammatory processes developing in the area of an impacted or dystopic tooth;
2.
Pain caused by compression of nerve trunks;
3.
Displacement of adjacent teeth;
4.
Fractures of the jaws with the fracture line passing through the area of the impacted or dystopic
tooth;
5.
Follicular cyst of the jaw.
Technique for removing impacted teeth
Before removing impacted teeth, a thorough clinical and radiological examination is necessary in order to
identify the exact localization of the tooth and its relationship to the maxillary sinus, nasal cavity, hard palate,
and mandibular canal. This allows you to draw up a surgical plan and avoid complications.
Local anesthesia (conduction in combination with infiltration), according to indications - anesthesia.
Intraoral access. The incision is made from the vestibular side of the alveolar process, cutting out a
trapezoidal mucoperiosteal flap. When the tooth is located closer to the hard palate, the incision is made from
the side of the hard palate. When the tooth is localized in the area of the angle or branch of the lower jaw,
extraoral access is used.
Operational reception. After cutting out the mucoperiosteal flap, the cortical plate of the alveolar process or
the body of the jaw is resected, exposing the tooth to be removed. Then the tooth dislocates into the wound.
In case of technical difficulties, the tooth is cut into pieces and removed.
The wound is sutured tightly. According to indications, tampon with an iodoform tampon for several days.
Control questions
1.
Define teething diseases.
2.
Classification of teething diseases.
3.
Causes of teething diseases.
4.
Clinic and diagnosis of teething diseases.
5.
List the indications for tooth extraction with complete retention and dystopia.
6.
Explain the choice of access when removing impacted teeth.
51
Tests
1.
Teething diseases include
a)
retentionc) follicular cyst
b)
periodontitis
2.
Teething diseases include
a)
dental dystopia) adicular cyst
b)
osteomyelitis
3.
There are different types of tooth retention
a) complete retention
b) incomplete retention
4.
Retention is
a)
delay in the eruption of a fully formed tooth through
compact jaw plate
b)
difficult tooth eruption
5.
Retention is more common
a)
upper canines
b)
lower canines
c)
upper and lower incisors
6.
Mandatory type of examination for teething diseases
teeth is
a)
tomography c) ultrasound
b)
ECGg) radiography
7.
The treatment method for incomplete tooth retention is a) orthodonticb) surgical
8.
The treatment method for dental dystopia is
a) orthodontic b) surgical
9.
The indication for removal of an impacted tooth is
a)
inflammatory process
b)
neuralgic pain
c)
deformation of the alveolar process
10.
Removal of an impacted tooth is accompanied by
incision of the mucous membrane with peeling of the mucoperiosteal
flap
a)
yes
b)
no
Situational tasks
Task 1. A patient came to the clinic with complaints of swelling and pain in the area of the missing tooth!3.
Previously, I noted this condition several times, took antibiotics on my own, after which these phenomena
disappeared.
Locally: tooth 13 is missing from the dental arch. The convergence of the crowns of teeth 12 and 14 is
determined. Palpation of the alveolar process reveals a protrusion of the outer cortical plate in the projection
of the missing tooth 13. The mucous membrane is swollen and hyperemic.
52
1.
Make a preliminary diagnosis.
2.
Make a plan for examination and treatment.
Task 2. An X-ray examination of the patient revealed complete retention of tooth 45. The patient’s bite is
adapted. There are no inflammatory phenomena. At the time of inspection he makes no complaints.
1.
Your tactics for managing the patient.
2.
Explain why.
TOPIC P. DIFFICULT ERUPTION OF THE LOWER THIRD MOLAR. CLINIC,
DIAGNOSTICS. COMPLICATIONS AND THEIR PREVENTION AND TREATMENT
Place of study - Dental clinic. Surgical office.
Lesson duration - 180 min. Purpose of the lesson
1.
To study the features of the eruption of the lower wisdom tooth and the topographic-graphicanatomical relationships of the area of its location.
2.
To study the causes of difficult eruption of lower third molars.
3.
Study the classification of complications of difficult eruption of the lower wisdom tooth.
4.
Study the clinic, diagnosis and methods of treatment of acute and chronic pericoronitis.
5.
Study methods for preventing complications of difficult eruption of the lower wisdom tooth.
The lower third molar usually erupts between the ages of J8 and 25 years and in most cases is a two-rooted
tooth with a strong crown.
The wisdom tooth is embedded in the branches of the lower jaw at the base of the coronoid process and
gradually moves down to the area of the inner corner of the lower jaw. By the time eruption begins, the
follicle of the wisdom tooth moves to the area of the inner corner of the lower jaw. Its roots are not yet fully
formed and the crown is separated from the mucous membrane by a significant bone layer. As the tooth
forms and grows, the bone layer becomes thinner and the pericoronal sac comes into direct contact with the
oral mucosa. The resulting canopy of the mucous membrane (hood) covers most of the tooth crown. As the
tooth grows, the hood dissolves and disappears by the end of eruption. The crown of the tooth is completely
freed and tooth eruption ends.
53
The area of the lower wisdom tooth has a number of features in its topographic-anatomical structure, which
have a certain
Rice. 14. Tooth eruption diagram
wisdom. Tooth relationship
and mucous membrane
influence on the clinical picture of difficult eruption of the lower third molar and its complications. The area
where the lower wisdom tooth is located is adjacent to layers of loose connective tissue located both on the
internal and external surfaces of the body and the anterior section of the ramus of the lower jaw. Thanks to
these layers of loose fiber, the retromolar area communicates with the surrounding fiber spaces, which can
lead to the spread of the inflammatory process to these spaces with serious consequences.
Causes of difficult eruption of the lower wisdom tooth
1.
Lack of space in the lower jaw, which can be caused by secondary reasons: as a result of trauma,
inflammatory process of the lower jaw, embryonic, endocrine disorders, excessively wide crowns of wisdom
teeth.
2.
Disruption of the embryonic development of the wisdom tooth due to too deep placement of the
tooth germ, its displacement.
3.
Pathology of the mucous membrane over the wisdom tooth.
The clinical picture of difficult eruption of the lower wisdom tooth is a clinical picture of complications that
may accompany this process. Difficulty in eruption is a primary phenomenon; the complication is secondary.
Classification of complications of difficult eruption of lower wisdom teeth
1. Inflammatory processes with the predominant involvement of the tissues covering and surrounding the
wisdom tooth
1.
Acute pericoronitis:
a)
catarrhal (serous);
b)
purulent;■
c)
ulcerative.
2.
Chronic pericoronitis.
542. Pathological processes in the soft tissues surrounding the lower jaw
1.
Acute periostitis.
2.
Abscesses and phlegmons.
3.
Ulcerative stomatitis.
3.
Pathological processes in the lower jaw
1.
Odontogenic osteomyelitis.
2.
Paradental cyst.
4.
Other complications
1.
Pathological processes in neighboring teeth.
2.
Neuralgia, neuritis, etc.
Pathogenesis of complications. Inflammatory complications arise due to the peculiar relationship of the tooth
with the oral mucosa. There are several options here,
1.
The tooth erupts in its normal position. The tooth is separated from the oral cavity only by the
mucous membrane. Under such conditions, microperforation of the mucous membrane is possible. The
infection easily enters the cavity of the pericoronary sac, which causes the development of the inflammatory
process.
2.
The tooth erupts in close proximity to the branch of the lower jaw. During eruption, the mucous
membrane over the medial tubercles atrophies faster, and the distal tubercles remain covered with a hood,
under which there is an accumulation of abundant microflora. The associated trauma contributes to the
development of the inflammatory process. Trauma can be caused by antagonistic teeth.
3.
The wisdom tooth is located abnormally. In these cases, conditions are also created for the formation
of a hood and injury.
The duration of eruption is also important. If nothing interferes with the movement of the tooth, then the
inflammatory phenomena stop quickly.
Clinical picture of perjoronaritis
Pericoronitis is an infectious and inflammatory disease of the mucous membrane of the pericoronary sac. It is
the most common and often the first complication of difficult eruption of the lower wisdom tooth.
Acute pericoronitis. The disease begins with unpleasant sensations in the area of the lower jaw behind the
second molar. Soon trismus sets in, pain when swallowing, a slight increase in temperature, and headache.
The mucous membrane in the area of the retromolar triangle becomes sharply hyperemic and edematous.
Upon careful examination, it is possible to differentiate three forms of inflammation:
55
1.
Catarrhal - the hood is swollen, hyperemic, infiltrated, the discharge from under it is serous.
2.
Purulent - pus is released from under the hood. Collateral edema, hyperemia and infiltration of
surrounding tissues develop early, pain when swallowing increases, and trismus increases. Bad breath and
hyperthermia are detected.
3.
Ulcerative - a violation of the integrity of the mucous membrane, ulceration of the hood is
determined. May precede diffuse ulcerative stomatitis.
There are three stages of acute pericoronitis:
1.
Mild - slight swelling of the hood, mild pain, lasting 2-3 days.
2.
Moderate severity - trismus appears. Suppuration from under the hood, pain when swallowing and
opening the mouth, lasting 4-5 days.
3.
Severe - the general condition worsens, trismus intensifies, inflammatory phenomena increase.
Chronic pericoronitis. Accompanies the eruption of lower wisdom teeth, which occupy the wrong position.
Palpation of the hood is slightly painful. Sometimes a scanty serous-purulent discharge is detected from
under the hood. The process develops slowly and may worsen. As a result of a long course, the hood
undergoes cicatricial degeneration. A long process causes the development of granulation tissue between the
crown of the tooth and the branch. The radiograph reveals the area of rarefaction of bone tissue at the crown
of the tooth and along the distal root of the tooth.
Diagnosis of difficult eruption of the lower wisdom tooth and its complications
Diagnosis is based on data from a clinical and x-ray examination of the patient. During the examination, you
should pay attention to the following points that will be important for drawing up a treatment plan:
1)
condition of soft tissues;(
2)
position of the lower wisdom tooth;
3)
the condition of the first and second molars;
4)
the condition of the upper third molar.
The lower wisdom tooth can be in the following positions:
1)
vertical;
2)
horizontal;
3)
medial oblique;
4)
distal oblique;
5)
linguistic;
6)
buccal.
56
Rice. 15. Diagram of the positions of the lower wisdom teeth: I - vertical; 2 - medial oblique; 3 - distal
oblique; 4 - horizontal (1 option); 5 - horizontal (option 2); 6-7 - buccal; 8 - lingual; 9 - combined
Treatment of acute pericoronitis
First of all, it is necessary to decide the fate of the tooth. The wisdom tooth should be preserved if it is
located vertically, there is enough space for it and there are no pathological changes in the surrounding bone
tissue, and there is no history of relapses of the inflammatory process.
Wisdom teeth to be removed:
1)
in any abnormal situation;
2)
in the presence of pathological changes in the surrounding bone tissue, even if the tooth is located
vertically;
3)
with insufficient space for complete eruption;
4)
with repeated inflammatory processes.
A very important question is: when to remove a tooth - in an acute period or after the inflammatory process
has subsided. If possible, one should strive to remove a wisdom tooth during an acute period, in the absence
of contraindications, since tooth extraction is one of the main therapeutic measures.
57
5.
Female student, 22 years old, complains of recurring
pain in the lower jaw on the left and difficulty opening the mouth. After
With polishing, these phenomena disappear. Objectively: in the left submandibular
In this area, a slightly painful moving node is palpated. Open
Mouth movement is slightly difficult, the mucous membrane behind tooth 37 is swollen,
uneven, slightly painful. From the little hole here
a drop of pus came out. When the probe is inserted into this hole, it is felt
dense tissue of tooth 37 - intact, does not respond to percussion. Before
before sending the patient for an x-ray, the doctor established a preliminary
positive diagnosis
a)
difficult eruption of tooth 38
b)
periostitis of the lower jaw on the left
c)
chronic osteomyelitis of the lower jaw on the left
d)
chronic granulating periodontitis of tooth 37
e)
pericoronitis in the area of the lower wisdom tooth
6.
Difficulty in eruption is most common
a)
upper wisdom teeth
b)
lower wisdom teeth
7.
The most common complication of difficult eruption
the lower wisdom tooth is
a)
periostitis) osteomyelitis
b)
pericoronoritis
8.
If tooth eruption is difficult, it is recommended
a) excision of the hood b) dissection of the hood
9.
A characteristic clinical symptom of pericoronoritis is
a)
restriction of mouth opening c) Vincent’s symptom.
b)
difficulty swallowing
10.
Removal of the lower wisdom tooth in case of acute pericoronoritis
is a treatment method
a) mandatory b) optional.
Situational tasks
Task 1. A patient came to the dental clinic with complaints of limited mouth opening and difficulty
swallowing. Locally: the mucous membrane of the retromolar region on the left is swollen and hyperemic.
The medial cusps of the lower third molar on the left have partially erupted. From under the hood there is a
scanty serous-purulent discharge.
1.
Make a preliminary diagnosis.
2.
What mandatory additional examination needs to be carried out?
3.
Make a treatment plan depending on the results of the additional examination.
60
Task 2. A patient came to the surgical office with the diagnosis: “Difficult eruption of the lower third molar
on the right. Acute catarrhal pericoronitis.” The distal oblique position of the tooth is determined clinically
and radiologically.
1.
Make a treatment plan for the patient.
2.
Specify the timing of the surgical intervention.
TOPIC 12. ODONTOGENIC OSTEOMYELITIS OF THE JAWS. CLASSIFICATION,
ETIOLOGY. MODERN IDEAS ABOUT PATHOGENESIS, PATHOLOGICAL ANATOMY
Place of class - Hospital. Department of maxillofacial surgery. Lesson duration - 180 min. Purpose of the
lesson
1.
To study the etiology and pathogenesis of odontogenic osteomyelitis of the jaws.
2.
Study the classification of odontogenic osteomyelitis of the jaws.
3.
Study the pathological anatomy of odontogenic osteomyelitis of the jaws.
Odontogenic osteomyelitis of the jaws is an infectious-allergic, purulent-necrotic inflammatory process in the
jaw bones involving the periosteum in the process, in which the source and entry point for infection and
sensitization of the body are previous diseases of the hard and soft tissues of the tooth and periodontium
Etiology of odontogenic osteomyelitis of the jaws
The most common source of pathogenic microflora in odontogenic osteomyelitis of the jaws are teeth with
gangrenous decayed pulp and infectious foci in the periodontium. From the inflamed and then necrotic pulp,
pathogenic microbes and their toxins enter the periodontium, where a corresponding inflammatory reaction
occurs, and then the septic material by contact or through the lymphatic and blood vessels enters the bone
marrow spaces of the jaw. Pathogenic microbes and their toxins can penetrate into the periodontal gap also
from the root canals of poorly filled teeth.
Pathogenic microflora can enter the bone marrow spaces through the lymphatic tract also from a living but
inflamed pulp (in acute purulent pulpitis).
Of great importance in the occurrence of osteomyelitis as a result of pulpitis is an overdose or prolonged
exposure of arsenic paste to
61
tooth cavity. The inflammatory process in the jaw bones is very unfavorable.
Much less often, pathogenic microflora penetrates the bone through the inflamed mucous membrane of the
hood due to difficulty in the eruption of wisdom teeth. Even less often, the source and entry point for
infection are gum pockets with periodontal disease or pathological processes on the mucous membrane.
There have been cases of osteomyelitis occurring after suppuration of the contents of radicular and follicular
cysts of the jaws, and the development of inflammatory processes in the area of impacted and dystopic teeth.
Sometimes osteomyelitis develops as a complication of tooth extraction surgery.
Among the microflora of osteomyelitic purulent foci, golden and white staphylococci, streptococci, gramnegative bacilli are more common, often in combination with anaerobic microflora. Increasingly, there are
strains of microorganisms resistant to antibiotics, which lead to the development of severe forms of
osteomyelitis with long-term and difficult treatment.
Pathogenesis
Currently, there are 4 main theories of the development of odontogenic osteomyelitis of the jaws.
1.
Infectious-embolic theory of Bobrov-Lekser. According to this theory, inflammation in the bone
occurs as a result of the transfer of a bacterial embolus and its sedimentation in the terminal capillaries, with
their thrombosis. The resulting disturbance of blood circulation and nutrition of the bone leads to its necrosis,
and the addition of infection to purulent inflammation. However, this theory is valid only under the condition
of the terminal structure of the capillaries. But the research of V.M. Uvarov proved the absence of an end
structure of the blood supply to the jaws and confirmed the presence of extensive anastomoses between the
vessels supplying the jaws, which largely refuted the Bobrov-Lekser theory.
2.
Infectious-allergic theory of Derizhanov. According to this theory, the disease can develop in a
sensitized organism in the presence of a dormant infection. Sensitization can occur during infectious diseases,
other suppurative processes, during absorption of decay products and under the influence of other causes, and
the resolving factor of allergy is any nonspecific irritation, including cooling, injury, etc. As a result of the
penetration of antigens into the bone tissue, a local allergic reaction develops here according to the
phenomenon
62
Artyusa-Sakharov with damage to the vascular endothelium, intravascular coagulation, stasis,
microcirculation disorders, tissue necrosis and subsequent development of inflammation.
3.
Neurotrophic (reflex) theory of Semenchenko. According to this theory of pathogenesis, the central
nervous system plays a leading role both in the occurrence of sensitization of the body and in disorders of the
blood supply to the bone, mainly in the occurrence of vascular spasm, which together creates conditions for
the development of osteomyelitis. As a result of prolonged irritation of peripheral nerves by hidden periapical
foci of inflammation, a disruption of trophic processes in bone tissue occurs, which leads to the formation of
focal necrosis in the latter. Pathological impulses constantly entering the cerebral cortex cause or maintain
vascular disorders in the bone. As a result, trophism in areas of constant irritation is disrupted and good
conditions are created for the development of infection.
4.
Endocrine theory of Solovyov. Increased secretion of glucocorticoids upon activation of the
hypothalamus-pituitary-adrenal cortex system delays the development of sensitization of the body and
suppresses the development of the inflammatory reaction. This system controls the course of the infectiousinflammatory process. However, the long-term existence of chronic foci of infection can lead to hidden
functional insufficiency of this system. Against this background, exposure to various irritants on the patient’s
body leads in some cases to depletion of the hypothalamus-pituitary-adrenal cortex system. This weakening
of control by the regulatory system is accompanied by activation of the infectious-allergic process.
The development of osteomyelitis of the jaws is influenced by such factors as the virulence of
microorganisms, the general immunological reactivity of the body, the state of local immunity, and the state
of blood circulation. Circulatory disorders play a leading role in the pathogenesis of osteomyelitis.
Intravascular coagulation causes tissue necrosis with the release of inflammatory mediators. This is
accompanied by increased exudation, increased intraosseous hypertension, and extravascular occlusion of the
efferent vessels. The observed slowdown in blood flow and overfilling of the microcirculatory bed, in turn,
promotes intravascular blood coagulation. Thus, a “vicious circle” is created, leading to the progression of
the process.
63
Violation
uejioctmrncimt vessels
during detachment
periosteum
Sdvvyaensh
vessels
zssuootom
'Armerium is being destroyed
tpressure
your jssudot&i
Thrombosis
veins
Dream" Delivery of venules Thrombt arterioles and Kvshkyarov shshshushrov
Rice. 17. Mechanisms of microcirculation disturbance in bone tissue in odontogenic inflammatory diseases
Knowledge of the etiology and pathogenesis of odontogenic osteomyelitis of the jaws is necessary to provide
correct etiopathogenetic treatment.
Pathological anatomy
The acute phase of odontogenic osteomyelitis is characterized by diffuse purulent inflammation of all bone
elements without pronounced demarcation of the process. It is manifested by edema, plethora and leukocyte
infiltration of the bone marrow, the contents of the bone nutrient canals and osteon canals, the periosteum
with adjacent soft tissues. The vessels are dilated and full of blood. Thrombosis and hemorrhage into the
tissue surrounding the vessels are observed. In the bone marrow there are areas of hemorrhage, multiple areas
of purulent infiltration with necrosis in the center. The periosteum is detached from the bone due to the
exudate accumulated under it.
In the chronic phase of odontogenic osteomyelitis, areas of osteonecrosis are clearly visible, around which
resorption of the adjacent healthy bone occurs. Areas of necrotic bone marrow are surrounded and replaced
by richly vascularized granulation tissue.
In a period of 1 to 2 months, the formation of sequesters is completed. The sequestrum is located in the
sequestral cavity, surrounded by the sequestral capsule. The sequestral cavity has a fistulous course.
64
After surgical removal or spontaneous discharge of the sequestrum, the sequestral cavity is replaced first by
connective tissue and then by bone. Only the dead alveolar process of the jaw is not restored.
Classification of odontohepatic osteomyelitis of the jaws
The classification takes into account the most significant features of the process according to the clinical
course, severity of the disease, localization and extent of the process, the nature of complications and the type
of pathological changes.
table 2
Classification of odontogenic osteomyelitis of the jaws
According to the clinical course (A) and severity of the disease (B)
According to the localization of
the process According to the prevalence of the process According to the nature of complications According to
the type of pathological-anatomical changes
A. Acute Subacute Chronic
Chronic in the acute stage
B. Lung
flow
Average
gravity
Severe Upper jaw Lower jaw Limited (alveolar process) Focal (body of the jaw within 3-4 teeth, angle or
branch) Diffuse (half the jaw or the entire jaw) Without complications
With complications (osteophlegmons, sepsis, mediastinitis, etc.) Destructive
Destructive-necrotic Destructive-plastic
Control questions
1.
Define odontogenic osteomyelitis of the jaws.
2.
Etiology of odontogenic osteomyelitis of the jaws.
3.
Outline modern theories of the pathogenesis of osteomyelitis.
4.
Describe the pathomorphological picture of osteomyelitis.
5.
Give the classification of odontogenic osteomyelitis of the jaws.
65
Tests
1.
The cause of the development of acute odontogenic osteomyelitis of the jaw
stey is
a)
acute mumps
b)
jaw fracture
c)
acute lymphadenitis
d)
decreased body reactivity
e)
injury from a poorly made prosthesis
2.
The cause of the development of acute odontogenic osteomyelitis of the jaw
disease is an inflammatory process
a)
in the lymph nodes d) in the maxillary sinus
b)
in the salivary glandsd) at the site of a jaw fracture
c)
in periapecal tissues
3.
The cause of the development of acute odontogenic osteomyelitis of the jaw
stey is
a)
acute mumps
b)
jaw fracture
c)
acute lymphadenitis
d)
exacerbation of chronic periodontitis
e)
exacerbation of chronic preiodontitis against the background of decreased reactivity
4.
Clinical picture of acute odontogenic osteomyelitis
love is
a)
in the mobility of all teeth in the jaw
b)
pain in the teeth, malaise, fistula tracts on the skin
c)
with chills, fever up to 40 °C, Vincent’s symptom, under
tooth visibility
d)
in acute, throbbing pain in the tooth, headache, positive
nom load symptom
5.
Local signs of acute odontogenic osteomyelitis are
are:
a)
mobility of all teeth in the jaw
b)
inflammatory infiltrate without clear boundaries
c)
muff-shaped infiltrate without clear boundaries, Vincent’s symptom,
tooth mobility.
d)
inflammatory infiltrate with clear boundaries, negative
symptom of stress.
6.
On the day of treatment for acute odontogenic osteomyelitis, it is necessary
we go:
a)
start acupuncture
b)
hospitalize the patient
c)
make a novocaine blockade
d)
prescribe physiotherapeutic treatment
e)
administer respiratory analeptics intramuscularly
7.
The causative tooth for odontogenic osteomyelitis is necessary
a)
removed) depulpate
b)
open d) replant
c)
seal
8.
In case of unfavorable course of acute odontogenic osteomia
Lita jaw can be a complication
a)
xerostomiad) facial paralysis
b)
salivary fistula) transition to a chronic form
c)
scar contracture
9.
In the treatment of acute odontogenic osteomyelitis of the jaw,
use drugs that have an osteotropic effect
a)
kanamycing) penicillin
b)
ampicillin) erythromycin
c) lincomycin
10.
To stimulate the body’s reactivity during the treatment of acute
odontogenic osteomyelitis of the jaw is used
a)
fusiding) methyluracil
b)
korglicond) erythromycin
c)
levomikol
Situational tasks
Task 1. A patient was admitted to the hospital with a diagnosis of “Acute osteomyelitis of the lower jaw on
the right.”
What examination is necessary to conduct to establish the etiology of osteomyelitis and formulate a complete
diagnosis?
Task 2. A patient was admitted to the hospital with complaints of dull aching pain in the area of the body of
the lower jaw on the left, the presence of purulent discharge from the fistula tract. An orthopantomogram
reveals the shadow of a sequestrum in the area of the body of the lower jaw on the left.
Make the correct diagnosis.
Topic 13. Acute stage of osteomyelitis of the jaws. Clinic, diagnostics, differential
diagnosis
Place of class - Hospital. Maxillofacial surgery department Duration of the lesson - 180 min. Purpose of the
lesson
1.
Study the clinical picture and diagnosis of acute odontogenic osteomyelitis of the jaws.
2.
Learn to carry out differential diagnosis of acute osteomyelitis of the jaws.
67
In the acute phase of the disease, patients first complain of pain in the area of one tooth, which is the source
of infection. Soon signs of periodontal inflammation of adjacent teeth appear. The pain intensifies, becomes
tearing, radiating along the branches of the trigeminal nerve.
One of the characteristic complaints with osteomyelitis of the lower jaw is a violation of the sensitivity of
half the lower lip and chin of the corresponding side (Vincent's symptom). The origin of this symptom is
associated with compression of the inferior alveolar nerve in the canal by exudate or the spread of the process
to the nerve trunk. In cases of the development of a purulent-inflammatory process in the soft tissues, the
pain seems to move beyond the jaw, complaints characteristic of peri-maxillary phlegmons appear (swelling,
jaw constriction, pain when swallowing, chewing).
Headache, general weakness, increased body temperature, loss of appetite, etc. are almost always observed.
Patients are pale. Pulse increased. In the area of the affected area of the jaw, infiltration and swelling of the
tissues are detected. There is a foul odor from the mouth. The causative tooth is initially motionless, but soon
becomes loose. Nearby teeth also become mobile: percussion of them is painful. The alveolar process of the
jaw is fusiformly thickened, and suppuration is noted from under the gums. The gums and mucous membrane
of the transitional fold in the area of the teeth involved in the purulent-inflammatory process are swollen and
hyperemic. Palpation is sharply painful. Pus accumulates under the periosteum of the alveolar process. When
pus penetrates into the surrounding cellular spaces, abscesses and osteophlegmons occur. In such cases,
infiltration of dense tissues and hyperemia of the skin are detected. Infiltration of soft tissues can spread to
the muscles of mastication and the muscles of the tongue and pharynx, which leads to impaired swallowing
and chewing functions.
Acute osteomyelitis of the upper jaw is characterized by a milder course, a shorter duration of the disease,
and the absence of extensive destruction of bone tissue. Osteomyelitis of the upper jaw is less often
complicated by severe phlegmon. This unique clinical course of osteomyelitis of the upper jaw is explained
by its anatomical and topographical features - good vascularization, the presence of a large number of holes
in the cortical substance, which facilitates the rapid evacuation of purulent exudate under the periosteum or
under the mucous membrane. The upper jaw, unlike the lower jaw, does not have massive muscle layers or
significant tissue spaces adjacent to it, so purulent leaks occur less frequently here. At the same time, there is
a danger of the process spreading into the infratemporal and pterygopalatine fossa, orbit and cranial cavity.
With odontogenic osteomyelitis of the upper jaw, in some cases the maxillary sinus is involved in the
inflammatory process.
68
Osteomyelitis of the jaws is characterized by symptoms of purulent-resorptive fever. Intoxication of the body
is most pronounced in diffuse, diffuse osteomyelitis, a hyperergic type of process.
The general reaction of the body is manifested by fever, increased heart rate and breathing, changes in blood
and urine. Body temperature can rise to 40 °C. Less commonly, with the hypergic type of the process, it can
be subfebrile.
A general blood test reveals neutrophilic leukocytosis with a shift to the left and accelerated ESR. Urine tests
reveal traces of protein, casts, and red blood cells.
X-ray changes in bone tissue characteristic of acute odontogenic osteomyelitis are not detected. The first
signs are detected on days 10-14, in the form of thinning of bone tissue, thinning of bone beams.
Control questions
1.
Specify the characteristic clinical symptoms of acute odontogenic osteomyelitis of the jaws.
2.
What is the peculiarity of the clinical picture of acute osteomyelitis of the upper jaw and what is this
connected with?
3.
Indicate with what diseases it is necessary to differentiate acute odontogenic osteomyelitis of the
jaws.
Tests
1.
Acute osteomyelitis of the jaw is characterized by pain
a)
constant in the jaw and several adjacent teeth
b)
nocturnal, paroxysmal only in the teeth
c)
in the jaw area and in one tooth
d)
in the teeth only from sour and sweet foods
2.
In case of acute osteomyelitis of the jaw in the first days, radiologists
clearly detectable bone changes
a) available
b) absent
3.
Mobility and pain from percussion of teeth, located
on the jaw affected by osteomyelitis - a consequence
a)
necrosis of bone beams
b)
purulent infiltration of the spongy layer of the jaw
c)
bilateral purulent inflammation of the periosteum
d)
intoxication of the body
e)
spread of infection from the periodontium of the affected tooth to the peneighboring rhodont
69
4.
More effective for the treatment of acute osteomyelitis of the jaw
a)
oxacilling) streptomycin
b)
furagind) penicellin
c)
lincomycin
5.
In the etiology of odontogenic osteomyelitis of the jaw, the least significant
significantly
a)
pathogenicity of microflora
b)
sensitization of the body
c)
decrease in the general resistance of the body
d)
structural features of individual teeth
e)
localization of individual teeth
6.
In acute osteomyelitis of the jaw, chills are associated with
a)
high body temperature
b)
bilateral acute purulent periostitis
c)
thrombosis of bone marrow vessels
d)
necrosis of the bone substance of the jaw
e)
cellular infiltration of bone marrow spaces
7.
Spread of infection through the bone marrow spaces
promotes jaw
a)
neutrophilic infiltration of the periodontium of the affected tooth
b)
neutrophilic infiltration of bone marrow
c)
bone marrow edema
d)
edema, bone marrow hyperemia
e)
any inflammation of the bone
8.
Leading factor in the pathogenesis of odontogenic osteomyelitis of the jaw
a)
penetration of infection into the periodontium of the “causal” tooth
b)
penetration of infection from the periodontium of the “causal” tooth into the bone
brain jaw
c)
decreased body reactivity
d)
sensitization of the body
e)
exacerbation of concomitant disease
9.
In acute osteomyelitis of the jaw, swelling of the face is observed
a)
true
b)
incorrect
10.
Osteomyelitis is an inflammation of bone tissue, accompanied by
necrosis of bone matter
a)
true
b)
incorrect
70
Situational tasks
Task 1. A patient came to the clinic with complaints of severe pain in the body of the lower jaw on the left,
limited mouth opening, difficulty swallowing, and general weakness.
Objectively: the patient’s general condition is of moderate severity. Pulse 90 beats per minute. Body
temperature 38 °C.
Locally: inflammatory swelling in the area of the body of the lower jaw on the left. The skin is slightly
hyperemic. Tooth 47 is cariously destroyed. The molars of the lower jaw on the left are mobile. Vincent's
sign on the left is positive.
1.
Make a preliminary diagnosis.
2.
Specify other symptoms of this disease.
Task 2. The patient complains of constant aching pain in the upper jaw on the left, radiating to the temporal
region, and an increase in body temperature to 39 °C.
Mestio: swelling and infiltration of the soft tissues of the infraorbital region on the left is determined, the
mouth opens 3 cm. The crown of tooth 25 is destroyed, a fusiform thickening of the alveolar process of the
upper jaw is determined on the left.
1.
Make a diagnosis.
2.
Specify other symptoms of the disease.
Topic 14. Treatment of odontogenic osteomyelitis in the acute stage
Place of class - Hospital. Department of maxillofacial surgery. Lesson duration - 180 min. Purpose of the
lesson
1. To study methods of treatment of acute odontogenic osteomyelitis of the jaws.
The treatment of acute odontogenic osteomyelitis of the jaws is based on the principles of etiopathogenetic
therapy:
1.
Impact on the pathogen, elimination of the source of infection;
2.
Treatment of the local outbreak;
3.
Conducting detoxification, desensitizing, anti-inflammatory therapy, improving blood
microcirculation.
Treatment of odontogenic osteomyelitis of the jaws in the acute phase should be aimed at eliminating the
purulent-inflammatory focus in the bone and surrounding soft tissues, taking measures to combat infection
and eliminating impaired body functions caused by the underlying disease.
71
vaniyam. Reducing the virulence of the infectious onset is achieved by active surgical intervention to drain
the purulent focus and includes removal of the causative tooth, dissection of soft tissues in case of
perimaxillary abscesses and phlegmon with drainage of the wound.
Removal of the causative tooth in the initial stage of the disease is the main and mandatory type of therapy
for this disease. This surgical intervention leads to the outflow of exudate from the bone marrow spaces and
to a decrease in intraosseous pressure, which improves blood circulation and prevents irreversible changes in
the bone associated with impaired microcirculation.
The complex of surgical treatment includes mandatory incisions in the oral cavity along the transitional fold
of the jaw, and, according to indications, external incisions.
Mobile teeth are preserved. As the inflammatory phenomena subside, these teeth become stronger.
In some cases, trepanation of the cortical plate of the jaw with a bur is recommended for decompression of
the medullary spaces.
Rice. 18. Bone trepanation in the acute phase of odontogenic osteomyelitis
Etiological treatment consists of the use of antibacterial therapy. It is recommended to use osteotropic
antibiotics (lincomycin, tetracycline, doxycycline, fusidine, etc.), broad-spectrum antibiotics (cephalosporins,
etc.). The dose, frequency of administration and route of administration depend on the age of the patient, the
severity of the disease and other factors.
Reducing general intoxication, improving the rheological properties of blood, correcting disturbances in
water-salt and protein balance, normalizing microcirculation and preventing the development of necrosis
along the periphery of the inflammation are achieved using decompressive trepanation
72
(tooth extraction), prescription of direct anticoagulants (heparin), drugs that improve microcirculation
(trental, dibazol, aspirin, etc.), intravenous administration of rheopolyglucin, hemodez, glucose, saline
solutions, drinking plenty of fluids.
To desensitize the body, antihistamines (diphenhydramine, suprastin, tavegil, etc.) and Ca chloride are used.
In severe cases, intensive therapy includes methods of extracorporeal detoxification - hemosorption,
lymphosorption, plasmapheresis.
Physiotherapy includes cold (1-2 days), ultraviolet irradiation of the lesion (from 2-3 days), ultraviolet
irradiation of blood, HBO therapy, electrophoresis of antibiotics, etc.
The patient should receive adequate nutrition high in proteins and vitamins.
Control questions
1.
What principles does the treatment of acute odontogenic osteom ielitis include?
2.
What is the surgical treatment of acute odontogenic osteomyelitis?
3.
What is the conservative treatment of acute odontogenic osteomyelitis of the jaws?
4.
How is bone marrow drainage achieved?
jaw wanderings?
Tests
1.
In the complex treatment of acute odontogenic osteomyelitis
Lusty comes in
a)
cryotherapy d) x-ray therapy
b)
HBO therapyd) electrocoagulation
c)
chemotherapy
2.
In the complex of treatment of acute odontogenic osteomyelitis of the jaw
therapy included
a) radiation
d) physiotherapy
b) sedative
d) hypotensive
c) manual
3.
Surgical treatment for acute odontogenic osteomyelitis
jaw is
a)
in the removal of the causative tooth
b)
in a wide periostotomy of the jaw on both sides
c)
to periostotomy in the area of the causative tooth, drainage
73
Topic 15. Subacute and chronic stages of odontogenic osteomyelitis of the jaws.
Clinic, diagnosis, differential diagnosis, treatment
Place of class - Hospital. Maxillofacial surgery department Duration of the lesson - 180 min. Purpose of the
lesson
1.
Study the clinical picture and diagnosis of subacute and chronic odontogenic osteomyelitis of the
jaws.
2.
Master the methods of differential diagnosis and treatment of acute and chronic odontogenic
osteomyelitis of the jaws.
The subacute phase of odontogenic osteomyelitis is short-term, most often lasting for 1.5-2 weeks. Its
duration is determined by several factors, among which the nature of the body’s reactivity, the timeliness and
volume of therapy for the patient in the acute phase should be highlighted. The subacute phase is
characterized by stabilization of the inflammatory process. Surgical tissues are cleaned of necrotic tissue,
granulated, and suppuration and swelling are reduced. A characteristic sign of the subacute stage is an
improvement in the general condition: weakness disappears. Sleep and appetite are normalized, body
temperature decreases, leukocytosis and ESR are significantly reduced.
Chronic odontogenic osteomyelitis is characterized by subsidence of pain and decreased infiltration of soft
tissues. In places of incisions or other areas of the skin and oral mucosa, fistulas with purulent discharge
appear. Rejection of sequesters is accompanied by the appearance of granulations from the fistula tracts.
Sequestra on the upper jaw are formed within 4-6 weeks, on the lower jaw - 5-8 weeks. In the area of the
osteomyelitic lesion, the jaw is thickened, the teeth are usually mobile. Probing the fistula reveals the uneven
contours of the sequestering bone.
A certain dependence of the nature of the resulting sequestration on the localization of the entrance gate of
infection is revealed. When the anterior group of teeth and premolars are affected, sequestration is limited to
the alveolar process or the middle part of the jaw body. In cases where the source of infection is the molars,
the angle and branch of the jaw may be involved in the inflammatory process.
With extensive destruction of the body of the lower jaw, a pathological fracture can occur.
As a result of a delay in the release of exudate through fistulas and the formation of purulent leaks, an
exacerbation of the inflammatory process may occur.
In some patients, reparative processes are more active than destructive ones. In these cases, hyperostotic
forms of osteomyelitis develop. There may be no fistulas here. Deformation of the jaw occurs.
76
A creeping form of osteomyelitis is possible, which, despite radical surgical interventions, is accompanied by
the appearance of new lesions. The disease lasts for years.
An important place in the diagnosis of chronic osteomyelitis belongs to x-ray examination. Sequestration has
the greatest diagnostic significance, the radiological symptom of which is the increased intensity of the
sequestration shadow. The shadow of the sequestrum stands out against the background of the more
transparent surrounding bone elements. Sometimes a demarcation zone is determined. Sequestration can be
of various shapes and localizations - central, peripheral and total.
Rice. 19. X-ray of patient M.
Fig. 20. Radiographs.
Primary chronic osteomyelitis Types of sequestration (a, b)
lower jaw: a- sequestration
of the lower jaw
bones; b - after treatment
Diagnosis is based on clinical and radiological examination data.
Chronic osteomyelitis is differentiated from specific lesions (actinomycosis, tuberculosis, syphilis), benign
and malignant tumors.
A large role in differential diagnosis is given to radiography, tomography, cytological examination, and, if
necessary, biopsy.
Treatment. In the subacute phase of osteomyelitis, antibacterial therapy is continued, preventing further
spread of the purulent-necrotic process. Measures are being taken to preserve micro77
circulation to prevent bone necrosis in new areas and accelerate the formation of sequesters. For this purpose,
agents are prescribed that stimulate metabolism in tissues: anabolic hormones, metacil, pentoxyl, proteolytic
enzymes, blood transfusion and blood substitutes, autohemotherapy, ultraviolet irradiation, UHF.
Simultaneously with drug and physical therapy, adequate drainage of the purulent cavity is carried out.
In the chronic phase of osteomyelitis, antibacterial and anti-inflammatory treatment is continued.
Sequestrectomy is performed. The timing of surgical intervention is determined individually.
For limited osteomyelitis of the upper jaw and alveolar process of the lower jaw, the operation is performed
through intraoral access. Sequestrectomy on the mandible requires an extracorneal approach.
Under reliable anesthesia, soft tissues are dissected and peeled off. The bone is trepanned within the
sequestral cavity. The sequesters are removed, and the granulations are scraped out to reveal healthy layers of
bone. Fistula tracts are excised. The sharp edges of the bone cavity are smoothed, filled with antibiotics and a
hemostatic sponge. The wound is sutured. Install drainage.
For extensive bone defects, primary or delayed bone grafting is performed.
According to indications, sequestrectomy should be preceded by splinting.
At the stage of stabilization of the chronic phase of odontogenic osteomyelitis, in the case of predominance
of reparative regeneration, measures are taken to prevent exacerbation of the inflammatory process, increase
immunological reactivity and enhance nonspecific protective factors through immunotherapy.
In the chronic phase of osteomyelitis, physical treatment methods are important. For this purpose,
electrophoresis of potassium iodide and calcium chloride is used on the lesion. If the process is sluggish,
electrophoresis of copper or zinc sulfate and ultrasound are prescribed. After sequestrectomy, mud therapy,
paraffin, and ozokerite are used.
Patients with odontogenic osteomyelitis should be treated in rehabilitation rooms, where regeneration
processes are monitored, oral cavity sanitation, and dental prosthetics are performed. Persons who have
suffered diffuse osteomyelitis of the jaws, as well as those who have had complications with vital organs,
should be under dispensary observation. All children with odontogenic osteomyelitis of the jaws are also
under clinical observation.
Control questions
1.
Indicate the characteristic clinical signs of the subacute stage of odontogenic osteomyelitis of the
jaws.
2.
Specify the characteristic clinical signs of chronic osteomyelitis of the jaws.
78
3.
What diseases need to be differentiated from chronic odontogenic osteomyelitis?
4.
What is the treatment for the subacute stage of osteomyelitis?
5.
What is the treatment for the chronic stage of osteomyelitis?
6.
Specify the timing of sequestrectomy on the upper and lower jaw.
7.
Describe the course of sequestrectomy on the upper and lower jaw.
8.
List the indications for medical examination of patients who have suffered odontogenic osteomyelitis
of the jaws.
Tests
1.
Not suitable for stimulating sequestration of dead bone
a)
blood transfusiond) vitamin injections
b)
autohemotherapyd) trypsin injections
c)
methyluracil tablets
2.
Bone sequestrum is a dead section of bone, separating
healthy
a) partially
b) completely
3.
Dead area of bone with osteomyelitis of the jaw opti¬
little removed
a)
3 weeks after the start of treatment
b)
6 months after the start of treatment
c)
before its complete separation from the healthy bone
d)
after its complete separation from a healthy bone
e)
after the cessation of suppuration from the fistula
4.
For chronic osteomyelitis of the lower jaw,
a)
fistulas and spontaneous fracture of the jaw
b)
bleeding and malocclusion
5.
A patient with chronic osteomyelitis of the jaw during surgery
pieces of necrotic bone were removed. However,
the scorching phenomena continued with the same intensity due to
a)
an insufficiently thorough operation
b)
untimely operation
c)
weakening the body's defenses
6.
When examining a patient who has been treated in a hospital for a long time
about acute osteomyelitis of the upper jaw, a moderate
swelling of the right infraorbital region, in the center of which you can see
A depression soldered to the bone, and at the bottom of it there are accumulations of granulations.
Regional lymph nodes are slightly enlarged and slightly painful. General
The patient's condition is satisfactory, body temperature is low-grade
Iaya. In the oral cavity from the vestibular and oral sides in the area of the teeth
79
15, 14, 13 the mucous membrane is edematous and cyanotic. Tooth 14 is missing, its socket is filled with
granulations. Tapping on teeth 16,15,13,12, 11 causes mild pain. Diagnosis established
a)
condition after tooth extraction 14
b)
acute osteomyelitis of the jaw
c)
subacute osteomyelitis of the jaw
d)
chronic osteomyelitis of the jaw
e)
neoplasm of the jaw
7.
Vincent’s symptom is a consequence of infiltration of the maxillary
soft tissue leukocytes
a) true b) false
8.
Sequestrectomy - surgical removal of dead tissue
decayed bone separated from healthy
a) true b) false
9.
To the decisive pathogenetic factors of odontogenic os¬
theomyelitis include
a) microflora b) sensitization of the body
10.
Least active in the treatment of acute osteomyelitis of the jaw
a) streptomycin d) sodium fusidine
b) lincomycin d) penicillin
c) tetracycline
Situational tasks
Task 1. The patient complained of mobility of teeth 21, 23, 24, the presence of fistulous tracts with purulent
discharge. From the anamnesis it is known that a month ago, after hypothermia, severe pain appeared in the
upper jaw area on the left and a sharp increase in temperature. I went to the clinic, where tooth 22 was
removed and an incision was made along the transitional fold of the upper jaw on the left, and antibiotics
were prescribed. My health has improved. The pain subsided. Subsequently, she did not consult a doctor.
Fistula tracts in the area of teeth 21, 23 and 24 appeared 2 weeks ago. The patient's condition is satisfactory.
Body temperature 37.1 °C. In the oral cavity: teeth 21, 23, 24 are mobile. The mucous membrane of this area
is hyperemic, loose, along the transitional fold corresponding to teeth 21, 23, 24, two fistulous tracts with
purulent discharge are identified.
1.
Make a diagnosis.
2.
What additional information is needed to make a final diagnosis? What additional examination needs
to be carried out?
Task 2. The patient was admitted to the clinic with complaints of aching pain and swelling in the lower jaw
area on the left. He has been ill for 1 year, when aching pain appeared in tooth 46, which was depulped and
filled.
S0
rovan. 2 months after this, swelling appeared in the area of the alveolar process and the body of the lower
jaw, and constant aching pain. Objectively: the general condition is satisfactory, the configuration of the face
has been changed due to deformation of the left half of the lower jaw. On palpation, the body of the lower
jaw is thickened and painful. The radiograph reveals a large number of small and medium-sized foci of bone
tissue destruction in the body of the lower jaw. The cortical plate along the edge of the jaw is destroyed.
1.
Make a clinical diagnosis.
2.
Make a plan for further examination and treatment.
Topic 16. Differential diagnosis of acute periodontitis, periostitis and odontogenic
osteomyelitis of the jaws
Place of class - Hospital. Maxillofacial surgery department Duration of the lesson - 180 min. Purpose of the
lesson
Learn to carry out differential diagnosis of acute periodontitis, periostitis and acute odontogenic osteomyelitis
of the jaws.
Differential diagnosis of acute periodontitis, periostitis and acute odontogenic osteomyelitis of the jaws is
carried out on the basis of clinical and anamnestic data.
The absence of signs of damage to the periosteum of the jaw and adjacent soft tissues distinguishes acute
periodontitis from osteomyelitis and periostitis. The focus of inflammation in periodontitis is limited mainly
to the hole of one tooth. The gums and mucous membrane of the transitional fold may be swollen, hyperemic
and painful on palpation, but only within one (affected) tooth. Percussion and pressure on the affected tooth
causes pain, the tooth becomes mobile. The patient's condition does not change significantly. Body
temperature and urine and blood test results are usually within normal limits. With timely treatment, recovery
occurs.
Acute purulent periostitis is accompanied by a disturbance in the general condition of the patient, low-grade
fever, and moderate changes in the blood. The source of inflammation is localized during periostitis on the
surface of the alveolar process. The process involves the periosteum and soft tissues; which leads to collateral
edema and the formation of subperiosteal abscesses. With periostitis, the transitional fold of the jaws is
smoothed, the mucous membrane is swollen and hyperemic, palpation is painful, and fluctuation can be
detected. But these changes are detected only on one side of the alveolar process over several teeth. With
timely surgical intervention and rational drug therapy, the process quickly stops.
81
In patients with acute odontogenic osteomyelitis, the general reaction of the body is more clearly expressed,
including changes in the blood and urine. Body temperature can rise to 40 "C. The pain syndrome is more
intense. Pronounced collateral edema is detected, the occurrence of perimandibular phlegmon is characteristic
of osteomyelitis. The alveolar process with osteomyelitis is fusiformly thickened, i.e. swelling and
infiltration, the formation of subperiosteal abscesses is noted with both sides of the alveolar process over
several teeth. There is mobility of several teeth, suppuration from under the gums. Vincent's symptom is
characteristic of osteomyelitis.
The radiograph does not reveal changes characteristic of acute periodontitis, periostitis or acute osteomyelitis.
Control questions
1.
On the basis of what general signs is the differential diagnosis of acute periodontitis, acute periostitis
and acute osteomyelitis carried out?
2.
On the basis of what local signs is the differential diagnosis of acute periodontitis, acute periostitis
and acute osteomyelitis carried out?
3.
Does X-ray examination have a differential diagnostic value when carrying out the differential
diagnosis of acute periodontitis, acute periostitis and acute osteomyelitis?
Tests
1.
Periodontitis and periostitis have a common pathological
changes in the vessels of the periosteum of the jaw
a) thrombosis b) expansion
2.
Constant weak aching pain only in tooth 33, intensified
occurs when closing teeth, chewing, touching a tooth with the lip, tongue
com, typical for
a) pulpitis
b) periodontitis
c)
periostitis of the jaw
d)
acute osteomyelitis of the jaw
e)
worsened chronic osteomyelitis of the jaw
3.
Periostitis differs from periodontitis in that the patient has
a)
difficulty opening the mouth
b)
percussion pain in one tooth
c)
inflammation of the gums
d)
increase in body temperature
d)
performance disorders
82
4.
Periostitis is distinguished from periodontitis by inflammation
a)
bone marrow and gums) cheeks
b)
bone marrowd) periodontal
c)
gums
5.
In case of acute osteomyelitis of the jaw and acute periodontitis,
There are similar pathological changes in bone tissue
a)
thrombosis of blood vessels
b)
infiltration of bone marrow spaces by neutrophils and lactation
Narre resorption of bone beams
c)
formation of sequestration of bone tissue in the chronic stage
d)
swelling and infiltration of bone canals by neutrophils and blood thrombosis
veins
e)
necrosis of bone substance
6.
Acute periodontitis and periostitis of the jaw are clinically brought together
„a) percussion pain in one tooth
b)
pain in the jaw area
c)
swelling of the cheek
7.
Thickening and soreness of the outer and inner surfaces
deformities of the lower jaw are detected in acute
a)
periodontitis) osteomyelitis
b)
periostitis
8.
Reaction to percussion and tooth mobility during acute periods
dontitis and osteomyelitis of the jaw
a) same b) different
9.
Acute periostitis and osteomyelitis of the jaw are similar
a)
necrosis of bone substance
b)
thrombosis of bone blood vessels
c)
hemorrhage in the bone marrow
d)
destruction of bone beams
e)
foci of purulent infection in the bone
10.
The doctor objectively discovered paresthesia of the lower lip on the right.
He suggested that the patient
a)
exacerbation of chronic periodontitis of tooth 46
b)
periodontitis of the lower right teeth
c)
acute periostitis of the lower jaw
d)
acute osteomyelitis of the body of the lower jaw
e)
acute osteomyelitis of the chin
83
Situational tasks
Task 1. A patient came to the clinic with complaints of severe pain in the lower jaw area on the right,
numbness of the skin of the right half of the lower lip, swelling in the cheek and submandibular areas on the
right. An examination of the oral cavity revealed mobility of several teeth in the lower jaw on the right. The
x-ray shows a loss of bone tissue at the medial root of the lower sixth tooth on the right.
1.
Make a preliminary diagnosis.
2.
Carry out differential diagnosis.
Task 2. A patient consulted a dentist with complaints of severe pain in the lower jaw area on the left,
radiating to the temple, swelling of the cheek area on the left, general weakness, and an increase in body
temperature to 37.3 C.
An examination of the oral cavity revealed infiltration of the transitional fold along the projection of the
lower second premolar on the left. The tooth is mobile, percussion is positive. Mouth opening is not limited,
swallowing is free.
1.
Make a preliminary diagnosis.
2.
Carry out differential diagnosis.
Topic 17. Odontogenic sinusitis. Pathogenesis. Classification. Clinic, diagnosis,
differential diagnosis
Place of class - Hospital. Maxillofacial surgery department Duration of the lesson - 180 min. Purpose of the
lesson
!. To study the etiology and pathogenesis of odontogenic sinusitis.
2.
Study the classification, clinical picture and diagnosis of odontogenic sinusitis.
3.
Learn to carry out differential diagnosis of odontogenic sinusitis.
Sinusitis is inflammation of the mucous membrane of the maxillary sinus.
Inflammation of the maxillary sinus develops most often with acute... rum rhinitis, infectious diseases,
especially respiratory ones. Sinusitis, which occurs as a result of infection of the sinus from the teeth, is
classified as odontogenic.
Odontogenic sinusitis is caused by pyogenic microflora. The most common causative agents of the disease
are Staphylococcus aureus and Staphylococcus epidermidis, Streptococcus, Escherichia coli, etc.
Relatively frequent infection of the maxillary sinus from odontogenic pathogenic foci is due to anatomical
and topographical
Chinese features of this area. With a low location of the maxillary sinus, the apices of the roots of premolars
and molars are separated from it only by a thin bone plate. In cases of periapical lesions, this plate may be
resorbed.
Relatively frequent damage and infection of the sinus during surgical and conservative treatment of molars is
explained by anatomical features.
Rice. 21. Relationship between the bottom of the maxillary sinus and the teeth of the upper jaw
The source of infection of the maxillary sinus was most often the periapical lesions of the upper second
premolars and first molars. In some cases, the source of sinus infection was pathological dental-gingival
pockets due to periodontitis. Inflammation of the maxillary sinus can occur with osteomyelitis and perihilar
cysts of the upper jaw, with mechanical pushing of the decay of the root canal into the sinus.
In the pathogenesis of sinusitis, a significant role is played by the general condition of the patient, recent
diseases that deplete the body and change its reactivity.
Classification of odontogenic sinusitis
1.
Acute sinusitis - serous, catarrhal, purulent, fibrous, hemorrhagic.
2.
Subacute.
3.
Chronic - parietal hyperplastic; polyposis.
4.
Chronic in the acute stage.
sch
Clinic
Acute odontogenic sinusitis. The disease is accompanied by a feeling of pressure and tension in the area of
the affected sinus, unilateral “stuffing” of the nose. In severe cases, sharp pain appears in accordance with the
location of the sinus, radiating along the branches of the trigeminal nerve. Odontalgia occurs due to the
involvement of the alveolar muscles in the process.
85
branches of the maxillary nerve. The disease occurs at elevated body temperature, and general weakness
appears.
Frequent symptoms of acute odontogenic sinusitis are headache, purulent discharge from the corresponding
half of the nose, increasing when the head is tilted, pain on palpation of the canine fossa, as well as on
percussion of teeth located in the bottom of the sinus. In some cases, the cheek becomes swollen. The sense
of smell and nasal breathing suffers.
Anterior rhinoscopy reveals swelling of the nasal mucosa, mucous or purulent discharge in the middle
meatus. Radiologically, acute sinusitis is characterized by a diffuse or parietal decrease in the airiness of the
maxillary sinus.
Subacute stage of odontogenic sinusitis. Clinically, subacute sinusitis is characterized by normalization of
general condition, body temperature, reduction of nasal discharge, and cessation of pain. The sense of smell
and nasal breathing may be restored.
Chronic odontogenic sinusitis. It may occur as a result of incomplete cure of an acute process or develop
without previous acute phenomena. The main symptoms of chronic sinusitis are purulent nasal discharge,
often with a foul odor, impaired nasal breathing, unilateral headache and a feeling of heaviness in the head,
paresthesia and pain in the area of the branches of the maxillary nerve. With sinus fistulas, there is usually no
nasal discharge.
An x-ray reveals a decrease in the transparency of the sinus, which, in the purulent form of sinusitis, becomes
intense and homogeneous. In the polypous form, parietal darkening and shadows of uneven size are detected.
Diagnosis of odontogenic sinusitis
Diagnosis of odontogenic sinusitis is carried out based on the following data:
1)
clinical and laboratory examination;
2)
radiography of the paranasal sinuses, orthopantomography; contrast maxillary sinusography,
according to indications - tomography (including computed tomography);
3)
puncture of the maxillary sinus;
4)
cytological examination;
5)
endoscopic examination and biopsy examination;
6) Ultrasound.
Differential diagnosis
Odontogenic sinusitis must be differentiated from acute periostitis and osteomyelitis of the upper jaw (in the
acute stage of sinusitis), rhinogenic sinusitis, perihilar cysts, tumors of the maxillary sinus, neuralgia and
trigeminal neuritis.
86
As a result of the ingrowth of perihilar cysts into the maxillary sinus, its walls are sharply deformed.
Subsequently, their thinning and even resorption occurs, which is clinically manifested by symptoms of
parchment crunching and fluctuation. When the cyst is located near the medial wall of the sinus, a protrusion
occurs in the lower nasal meatus (Gerber's cushion). When the cyst is localized in the area of the sinus
bottom, the alveolar process of the upper jaw is deformed. Radiography helps in differential diagnosis with a
cyst. X-ray examination reveals a rounded area of clearing with smooth edges.
Malignant tumors of the maxillary sinus in the initial stages have a clinical picture similar to that of chronic
sinusitis. But with a tumor, the pain is more persistent and gradually intensifies. There is spotting or
nosebleeds. Conventional anti-inflammatory treatment is not successful. The growing tumor deforms the
upper jaw, displaces the eyeball, and destroys the walls of the sinus, which can be seen on radiographs. The
final answer is given by cytological or histological examination.
Differential diagnosis with periostitis, osteomyelitis is carried out on the basis of clinical and radiological
examination.
Odontogenic sinusitis has a number of differences from rhinogenic sinusitis:
1)
tooth pain preceding the disease;
2)
the presence of an inflammatory process in the area of the upper jaw, corresponding to the bottom of
the sinus (periodontitis, parodoititis);
3)
the presence of a perforation or fistula in the bottom of the sinus;
4)
pain on palpation of the anterolateral wall of the sinus;
5)
the presence of foul-smelling purulent discharge from the spit, crumbly-curdled masses in the
washing waters;
6)
isolated lesion of one maxillary sinus;
7)
with odontogenic sinusitis, the bottom of the sinus is predominantly affected;
8)
with odontogenic sinusitis, the pathological process leads to more severe organic changes, up to the
destruction of the bone tissue of the sinus walls.
Control questions
, 1. Specify the main reasons for the development of odontogenic sinusitis.
2.
Classification of odontogenic sinusitis.
3.
Indicate the characteristic clinical symptoms of acute and chronic sinusitis.
4.
What examination methods are used to diagnose sinusitis?
5.
What diseases must be differentiated from odontogenic sinusitis?
6.
Carry out a differential diagnosis with rhinogenic sinusitis.
87
Tests
1.
The maxillary cleft communicates the maxillary sinus with
a)
ethmoidal labyrinth d) middle nasal meatus
b)
upper nasal passage d) oropharynx
c)
lower nasal meatus
2.
In acute odontogenic maxillary sinusitis, a) swallowing b) breathing is impaired
3.
Maxillary sinusitis is an inflammation
a)
walls c) mucous membrane and walls
b)
mucous membrane
4.
The patient was admitted again with complaints of pain and swelling
in the left half of the face, nasal congestion, purulent discharge from the left
nostrils Objectively: daytime body temperature is 36.8 °C. Nasolabial
the fold on the left is smoothed, the tissues of the infraorbital region are thickened, the skin
pale pink, gathers into a fold. Palpation of the anterior-outer
the surface of the upper jaw on the left is painful. Anterior rhinoscopy:
cyanosis and hypertrophy of areas of the mucous membrane. Mucous membrane
the upper vault of the mouth on the left is hyperemic, swollen, on the palate side
- pale pink. The roots of tooth 26 are filled and react to percussion.
this. A preliminary diagnosis has been established
a)
acute periostitis of the upper jaw
b)
osteomyelitis of the upper jaw
c)
abscess of the infraorbital region
d)
exacerbation of chronic maxillary sinusitis
5.
The most significant sign of acute maxillary sinusitis
a)
constant pain
b)
pain when feeling the walls
c)
high body temperature
d)
copious nasal discharge
e)
drops of pus in the middle meatus
6.
Acute maxillary sinusitis is characterized by
a) exophthalmos
b) swelling of the lower eyelid
7.
In the acute stage of maxillary sinusitis,
a)
unilateral headache
b)
numbness of the facial skin
8.
Acute purulent maxillary sinusitis is differentiated from
sharp
a) purulent periodontitis b) osteomyelitis of the jaw
9.
Odontogenic maxillary sinusitis is not characterized by a fistula
a) in the area of the extracted tooth
b) on the skin of the face
Y
THAT. The maxillary sinus is bounded above and below by the bottom of the orbit and the hard palate
a) true b) false
Situational tasks
Task 1. The patient has been experiencing low-grade fever for a month, pain in the area of the upper jaw teeth
on the right, and purulent discharge from the right half of the nose.
1.
Make a preliminary diagnosis.
2.
List the methods of examining the patient.
Task 2. The patient complains of purulent discharge from the left half of the nose, a feeling of heaviness in
the upper jaw on the left. I've been sick for about a month. During the initial examination, pain upon
palpation of the anterior wall of the maxillary sinus on the left and hyperemia of the nasal mucosa on the left
are noted. In the oral cavity, teeth 25 and 26 are destroyed.
1.
Establish a diagnosis.
2.
Carry out differential diagnosis.
Topic 18. Methods of conservative and surgical treatment of odontogenic sinusitis
Place of class - Hospital. Department of maxillofacial surgery. Lesson duration - 180 min. Purpose of the
lesson
1. To study methods of conservative and surgical treatment of odontogenic sinusitis.
Treatment of acute sinusitis should be comprehensive. The tooth that is the source of infection must be
removed. To improve the outflow of exudate, vasoconstrictor drugs (5% ephedrine solution, naphthyzine,
galazolin) are injected into the nose. Of particular importance in the treatment of sinusitis is puncture of the
maxillary sinus, which is carried out either through the lower nasal passage or through the anterior wall of the
sinus, followed by washing it with medicinal solutions (sodium hypochlorite, furacillin, dimexide, etc.). To
facilitate flushing of the sinus, a catheter is inserted into it. If necessary, the number of washes is increased to
3 times a day.
89
Rice. 22. Puncture of the maxillary sinus
At the same time, antibacterial, anti-inflammatory, restorative therapy, and physical therapy are carried out.
Opening the sinus in acute sinusitis is very rarely performed. The indication for maxillary sinusotomy is sinus
empyema with the development of intracranial complications.
Chronic odontogenic sinusitis is treated with conservative and surgical methods. Treatment consists of
removing pathological contents from the sinus, restoring its drainage function, and conducting general and
local etiotropic and pathogenetic therapy.
Both conservative and surgical treatment of chronic sinusitis begin with the elimination of the odontogenic
inflammatory focus. Then conservative treatment is carried out using sinus drainage for 1-2 weeks.
Before introducing antibiotics into the sinus, it is washed with antiseptic solutions. The results of local
therapy are significantly improved after preliminary introduction into the sinus of proteolytic enzymes
(trypsin, chymotrypsin), which have a pronounced mucolytic, fibrinolytic, anti-edematous and antiinflammatory effect.
Local treatment is supplemented with physiotherapy (UHF, microwave, laser therapy, etc.).
If conservative treatment is ineffective, surgical treatment is used. Indications for surgical treatment are:
1)
parietal hyperplastic sinusitis, which cannot be treated for a long time;
2)
polypous sinusitis;
3)
fistula of the maxillary sinus with the development of an inflammatory process in the sinus;
4)
a radicular cyst that has grown into the sinus and caused its inflammation;
5)
foreign body of the sinus.
The choice of surgical treatment method depends on several conditions:
1)
is there a connection between the maxillary sinus and the oral cavity;
2)
whether there is germination of a perihilar cyst into the sinus;
3)
whether surgical intervention on the sinus was previously performed.
I
90
The standard procedure for the maxillary sinus is a radical Caldwell-Luc rhinotomy.
Surgeries on the maxillary sinus are performed under local or general anesthesia.
The main stages of the Caldwell-Luc operation are:
1)
incision along the transitional fold of the upper jaw from the second molar to the lateral incisor:
2)
skeletonization and resection of the anterolateral wall of the sinus:
3)
removal of pus, polyps, mucous membrane from the sinus;
4)
the formation of a wide sinus anastomosis with the lower nasal passage;
5)
loose tamponade of the sinus with an iodoform swab;
6)
suturing the wound.
The tampon is left in the wound to stop bleeding for 3-5 days. Currently, it is recommended to remove not
all, but only the pathologically altered mucous membrane.
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Rice. 23. Scheme of radical surgery
on the maxillary sinus according to Caldwell-Luc.
-a - cut line; b - expansion of the burr hole
medial lateral wall with pieces of Gajek; c- excision of the mucosa
sinus membranes; d - screwing a flap of mucous membrane into the sinus
If there is a perihilar cyst that has grown into the maxillary sinus, the following operations are performed:
i) Maxillary sinusotomy with simultaneous cystectomy, as a result of which the cyst membrane is completely
removed. The operation ends in a typical way.
91
2) Maxillary sinusotomy with cystotomy. Indicated in cases where it is impossible to completely remove the
cyst shell. The essence of the operation is to connect the cavity of the cyst and the sinus into one large cavity,
as a result of which the growth of the cyst stops. The operation is completed in a typical manner.
If there is communication between the sinus and the oral cavity, surgical intervention is performed on the
maxillary sinus with immediate excision of the fistula and elimination of this communication.
During operations on the maxillary sinus with simultaneous elimination of communication with the oral
cavity and removal of the cyst, the Zaslavsky-Wassmund surgical approach is used, which allows for revision
of the alveolar process of the jaw and closing the defect of the sinus floor.
Rice. 24. Formation of a trapezoidal flap according to Zaslavsky
In order to achieve success in the treatment of odontogenic sinusitis, it is necessary to wisely combine
conservative and surgical treatment methods.
Control questions
1)
What is the conservative treatment of odontogenic sinusitis?
2)
What is the indication for opening the maxillary sinus in acute sinusitis?
3)
What is the indication for surgical treatment of chronic sinusitis?
4)
What determines the choice of method of surgical intervention on the maxillary sinus?
5)
List the stages of the Caldwell-Luc operation.
6)
What surgical interventions are indicated for the growth of a radicular cyst into the maxillary sinus?
7)
What access is advisable to use if it is necessary to simultaneously close a defect in the sinus floor?
92
Tests
1.
Patient, 40 years old, has been suffering from chronic right
third-party maxillary sinusitis, exacerbating 1-2 times a year.
He was treated conservatively. Tooth 15 was removed 2 years ago. Currently
time after cooling, a scanty purulent-serous discharge appeared
from the right half of the nose, general weakness, chills, heaviness in the area
upper jaw on the right, impaired sensitivity of the upper lip and
infraorbital region on the right. Mouth opening is free, mucous
the membrane of the upper vault of the mouth on the right is hyperemic and painful. Per¬
The bite of the intact upper teeth and the filled tooth 16 is painful.
The radiograph revealed a homogeneous darkening of the right upper
maxillary sinus. Body temperature 37 "C. Diagnosis established
a)
acute periostitis of the upper jaw
b)
acute osteomyelitis of the upper jaw
c)
exacerbation of chronic maxillary sinusitis
d)
exacerbation of chronic periodontitis of tooth 15
e)
periodontitis of the upper teeth on the right
2.
For chronic maxillary sinusitis with periodic
exacerbations are advisable first of all
a)
remove the disturbing and long-treated upper molar
b)
puncture and rinse the sinus with antibiotics
c)
perform a radical Caldwell-Luc operation
d)
prescribe vasoconstrictor drugs to the nose
3.
In acute odontogenic maxillary sinusitis,
a) swallowing b) breathing
4.
In case of chronic polypous maxillary sinusitis, pro¬
contraindicated
a)
removal of polyps through the tooth socket
b)
puncture evacuation of exudate
c)
radical sinusotomy
V) coagulation of polyps through the anastomosis in the lower nasal meatus
e)
physiotherapy
5.
Conservative treatment of acute purulent maxillary sinus
Nusita was ineffective. It is advisable first of all to produce
a)
incision of the soft tissues of the upper vault of the vestibule of the mouth
b)
sinusotomy
c)
radical sinusotomy
93
d)
puncture of the maxillary sinus
e)
external novocaine blockades
6.
Radical maxillary sinusitis is performed under a wire
pain relief
a)
tuberal, palatal, incisive
b)
incisive, palatal, infraorbital
c)
infraorbital, superficial (in the nasal cavity), tuberal, palatal
7.
Reliable diagnosis of chronic diffuse, polyposis
maxillary sinusitis is placed on the basis
a)
systematic entry of liquid from the mouth into the nose
b)
detecting a filling defect on the top X-ray
non-maxillary sinus filled with contrast material
c)
decreased transparency of the maxillary sinus according to X-ray data
genograms
d)
frequent exacerbations of chronic inflammation
e)
the presence of a fistulous tract with bulging granulations in the area
extracted tooth sockets
8.
If the patient has acute maxillary sinusitis, when
rhinoscopy there is pus in the middle meatus, the appointment of UHFtherapy
a) shown
b) not shown
9.
For acute maxillary sinusitis, the presence of exophthalmos
a) characteristic b) not characteristic
10.
If body temperature rises after injection of piRogenel dose of the drug should be
a)
reduce. c) leave unchanged
b)
increase
Situational tasks
Task 1. The patient was diagnosed with acute odontogenic sinusitis on the right, the root of tooth 15 was
removed. There was no opening of the bottom of the sinus. Describe your treatment plan.
Task 2. The patient is diagnosed with chronic polypous sinusitis to the right of the 17th tooth. Previously
carried out conservative treatment is ineffective.
Make a treatment plan.
94
Topic 19. Perforation and fistula of the maxillary sinus. Causes. Clinic, diagnosis,
doctor’s tactics, treatment
Place of class - Hospital. Department of maxillofacial surgery. Lesson duration - 180 min. Purpose of the
lesson
1.
Study the meaning of the terms “perforation” and “maxillary sinus fistula”.
2.
To study the causes of perforation and fistula of the maxillary sinus.
3.
Study the clinic and methods of diagnosing perforation and fistula of the maxillary sinus.
4.
Study methods for eliminating perforation and fistula of the maxillary sinus.
5.
Master the tactics of patient management depending on the conditions of occurrence and detection of
communication between the maxillary sinus and the oral cavity.
Perforation of the sinus floor is an unstable connection between the maxillary sinus and the oral cavity, which
occurs acutely after tooth extraction.
A maxillary sinus fistula is a persistent connection between the maxillary sinus and the oral cavity, lined with
epithelium from the inside, usually resulting from perforation of the sinus floor.
Causes of perforation and fistula of the maxillary sinus
1.
Anatomical and topographic relationship of the bottom of the maxillary sinuses with
roots of teeth.
2.
Traumatic tooth extraction.
3.
A long-term inflammatory process in the area of the apex of the cornea, leading to the destruction of
the bottom of the sinus.
Causes of maxillary sinus fistula:
1.
Late diagnosis of perforation.
2.
The presence of an inflammatory process in the sinus during the formation of perforation.
Clinic and diagnosis of perforation and fistula of the maxillary sinus.
With perforation and fistula of the maxillary sinus, patients usually complain of fluid entering the nasal
cavity. For diagnosis, nose-to-mouth and mouth-to-nose tests are used. When performing a nose-to-mouth
test, the patient is asked to exhale through a closed nose. In this case, foamy blood appears from the socket of
the extracted tooth. When performing a mouth-nose test, the patient is asked to inflate his cheeks, which is
not possible if there is perforation of the bottom of the maxillary sinus. If perforation occurs, blood may
appear from the corresponding half of the nose.
When perforation occurs during an examination of the oral cavity, it is discovered that the hole is not filled
with a blood clot. If there is a fistula, according to the projection
95
the hole reveals a pinhole; during probing, the probe easily penetrates the sinus.
In the presence of a fistula, chronic sinusitis usually develops, which is manifested by the appropriate clinic.
Tactics of a dentist when perforation of the sinus floor is detected
Depends on the following conditions:
1.
From the timing of perforation formation
2.
The presence or absence of a foreign body in the sinus.
3.
From the presence or absence of an inflammatory process in the maxillary sinus.
1.
When diagnosing perforation immediately after tooth extraction and in the absence of an
inflammatory process and a foreign body in the sinus, it is necessary to immediately close the perforation
hole using one plastic method or another. Treatment is possible in a clinic setting.
2.
If perforation is detected late and there is no foreign body or inflammatory process in the sinus, then
it is also possible to close the defect without intervention in the maxillary sinus.
3.
If perforation is accompanied by the presence of a foreign body in the sinus, a maxillary sinusotomy
with immediate closure of the sinus defect is indicated. Treatment in a hospital setting.
4.
If perforation of the sinus floor is accompanied by the presence of an inflammatory process in the
sinus, then maxillary sinusotomy is also indicated. Before surgery, it is necessary to stop the inflammatory
process in the sinus. Why is it necessary to separate the oral cavity from the maxillary sinus by making a
protective plate of plastic or tamponade of the socket with iodoform turunda. General and local antiinflammatory therapy is carried out.
5.
Since a fistula is almost always accompanied by perforation of the sinus, surgical intervention in a
hospital setting is indicated.
Ways to eliminate communication between the sinuses and the oral cavity
There are two most common methods for surgically eliminating a sinus floor defect.
1. Elimination of a sinus defect with a buccal-alveolar flap according to Wassmund
The operation is performed under local anesthesia. The edges of the defect are refreshed. A trapezoidal
mucoperiosteal flap is cut out from the vestibular side of the alveolar process, with the base facing the cheek.
For better immobilization, the periosteum is incised at the base of the flap. The flap is moved to the defect
and fixed with sutures.
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Rice. 24. Plastic closure of the defect
perforation of the maxillary sinus
a - cut line; b - detachment of the buccal-gingival flap;
c- excision of the epithelialized edges of the defect and the edges of the exfoliated
flap; d - fixation of the flap in place with sutures
2. Removal of the sinus with a palatal flap according to Limberg
Under local anesthesia, after refreshing the edges of the defect, a tongue-shaped mucoperiosteal flap is cut
out from the palate, with the base facing the palate. The flap contains the palatal neurovascular bundle. The
apex of the flap is at the level of the canine. The flap is moved to the defect and fixed with sutures. The
wound surface on the palate is covered with an iodoform swab.
Rice. 25. Plastic closure of the perforation hole of the maxillary sinus with buccal-gingival and palatal flaps
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The remaining methods for eliminating the defect are modifications of the methods listed above and do not
have any great advantages over them.
If there is a large defect, both methods are used.
To achieve better results in the postoperative period, anti-inflammatory therapy is used and the suture line is
covered with a protective plate to prevent injury to the suture line while eating.
Control questions
1.
What is the difference between perforation and fistula of the maxillary sinus?
2.
List the causes of perforation and fistula of the maxillary sinus.
3.
What clinical symptoms are characteristic of perforation of the maxillary sinus floor?
4.
What conditions influence the doctor’s tactics when detecting perforation of the sinus floor?
5.
List the methods for closing the sinus floor defect and eliminating sinus
now the maxillary sinus.
Tests
1.
The most informative way to identify a hole message
extracted tooth with maxillary sinus
a)
radiography of the hole
b)
determining the depth of the hole
c)
determination of the density of the bottom of the hole
d)
detecting the movement of air from the mouth to the nose and back
e)
palpation and percussion of the sinus walls
2.
When treating a patient with perforation of the bottom of the maxillary sinus
nous that arose during the removal of tooth 27 should not be socketed
a)
tampon all the way to the bottom
b)
pack the mouth loosely
c)
immediately after the operation, sutured tightly
d)
suturing tightly after anti-inflammatory therapy
e)
leave it open
3.
To establish a diagnosis of perforation of the maxillary sinus
during the removal of an upper molar, the most informative symptom is
a)
discharge of pus from the socket
b)
copious bleeding from the socket
c)
discharge of blood from the nose
d)
absence of blood in the socket
e)
immersion of the curettage spoon above the bottom of the hole.
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4.
During removal, the palatal root of tooth 26 was advanced to the upper
maxillary sinus. In this case, it is advisable to take
a)
tight tamponade of the mouth of the socket
b)
immediately try to extract the root
c)
sinus lavage
d)
loose tamponade at the mouth of the socket
e)
urgent hospitalization of the patient
5.
Perforation of the maxillary sinus during tooth extraction
contributes more
a)
anatomical proximity of the roots of the teeth to the sinus
b)
chronic granulating periodontitis of adjacent teeth
6.
In the acute stage of maxillary sinusitis,
a)
unilateral headache
b)
numbness of the facial skin
7.
Acute purulent maxillary sinusitis is differentiated from
sharp
a) purulent periodontitis b) osteomyelitis of the jaw
8.
In case of chronic polypous maxillary sinusitis, pro¬
contraindicated
a)
removal of polyps through the tooth socket
b)
puncture evacuation of exudate
c)
radical sinusotomy
d)
coagulation of polyps through the anastomosis in the lower nasal meatus
e)
physiotherapy
9.
The method of closing the sinus floor defect is
a) According to Wasmund
b) According to Caldwell-Luke
10.
When closing a sinus floor defect according to Linberg, it is used
a) buccal flap b) palatal flap
Situational tasks
Task 1. When tooth 26 was removed, perforation of the maxillary sinus occurred. The surrounding tissues are
not injured. There is no history of clinical symptoms characteristic of sinusitis.
Describe the tactics of a dental surgeon at a clinic.
Task 2. When removing tooth 28, the doctor pushed the palatal root into the maxillary sinus.
Describe the doctor’s tactics in this situation.
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Topic 20. Acute lymphadenitis of the face and neck. Classification. Clinic, diagnosis,
differential diagnosis, treatment
Place of class - Hospital. Maxillofacial surgery department Duration of the lesson - 180 min. Purpose of the
lesson
1.
Study the anatomy of the lymph nodes of the maxillofacial region and neck.
2.
To study the etiology and pathogenesis of lymphadenitis of the maxillofacial area and neck.
3.
Study the classification of lymphadenitis of the face and neck.
4.
Study the clinical picture and diagnosis of acute lymphadenitis of the face and neck.
5.
Master the methods of differential diagnosis and treatment of acute lymphadenitis of the face and
neck.
Lymphadenitis is inflammation of the lymph node.
Lymph nodes of the head are represented by groups of occipital, mastoid, buccal, superficial and deep parotid
lymph nodes.
The lymph nodes of the neck are represented by groups of submental, submandibular, retropharyngeal,
anterior and lateral lymph nodes of the neck, which are divided into superficial and deep.
Rice. 26. Lymph nodes of the face and neck (according to Kirschner)
1 - submental; 2 - submandibular; 3 - buccal;
4 - parotid; 5 - anterior ears; b - superficial cervical;
7 - angular vein; 8 - superficial temporal vein;
9 - superficial temporal artery; 10 facial vein
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The reason for the frequent damage to the lymph nodes is explained by the role they play in maintaining
homeostasis. Through regional lymph nodes, lymph flowing from the tissues of the corresponding region is
filtered. At the same time, bacteria, toxins, foreign Hb1X proteins and tissue decay products are retained in
the lymph nodes.
Etiology and pathogenesis. The causative agent of acute lymphadenitis of the maxillofacial region and neck
is most often pathogenic staphylococcus in the form of a monoculture or in association with streptococcus
and various anaerobes.
The source of infection can be odontogenic, tonsilogenic, stomatogenic, rhinogenic, dermatogenic infections.
Microbes that penetrate the lymph node are retained in the reticuloentothelial cells and undergo phagocytosis.
The virulence of the infectious agent decreases. If the microbes are not completely destroyed, they, adapting
to new conditions of existence, begin to multiply. Their number can reach a critical mass, at which a local
infectious-inflammatory process develops.
Classification of lymphadenitis
1.
Acute-serous; purulent; abscess;
2.
Chronic - productive; abscessing. Clinic
Acute serous lymphadenitis is characterized by the appearance of pain and enlargement of the lymph node.
General condition is satisfactory. An enlarged, painful lymph node is palpable, mobile, not fused to the
underlying tissues. The skin over it is not changed in color.
Acute purulent lymphadenitis occurs as a result of the transition of a serous process to a purulent one. It is
characterized by the appearance of severe pain in the affected lymph node. General health worsens, body
temperature rises. The skin over the lymph node is hyperemic and difficult to fold. Upon palpation, an
enlarged, dense, painful lymph node is determined. When the process is localized in the area of the neck
nodes, pain may appear when swallowing.
Acute abscessing lymphadenitis is characterized by the development of periadenitis, i.e. spread of the process
beyond the lymph node. The pain increases sharply, the function of swallowing and chewing is impaired.
General weakness and hyperthermia appear. The skin in the area of the abscess is hyperemic and does not
fold. The lymph node is practically not palpable; fluctuation can be detected.
With further development of the process, adenophlegmon is formed.
Diagnosis of acute lymphadenitis is based on clinical examination data. A puncture with cytological
examination of the punctate and ultrasound can be performed.
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Differential diagnosis is carried out from specific diseases of the lymph nodes.
Treatment of acute lymphadenitis is complex. If it is possible to identify the primary source of infection, then
measures are taken to eliminate it. At the same time, they influence the secondary infectious focus, i.e. to the
affected lymph node.
In the stage of serous inflammation, physiotherapy is effective: UHF, microwave therapy, helium-neon laser.
Short novocaine blocks according to A.V. are effective. Vishnevsky with the addition of antibiotics to the
anesthetic.
Prescribed drugs that stimulate the immune system, increasing the body's resistance to infection: calcium
chloride, aspirin, dibazol, Eleutherococcus, vitamin therapy.
According to indications, anti-inflammatory therapy is carried out.
In case of acute purulent lymphadenitis, abscess, or adenophlegmon, urgent surgical intervention is indicated
- opening and drainage of the abscess. The choice of surgical access and surgical intervention technique
depend on the localization of the inflammatory process.
Control questions
1.
Indicate possible primary sources of infection for lymphadenitis of the face and neck.
2.
List the groups of lymph nodes of the maxillofacial region and neck.
3.
What forms of acute lymphadenitis are distinguished?
4.
Indicate the characteristic clinical symptoms of acute lymphadenitis depending on the form of the
inflammatory process and its localization.
5.
What is the treatment for acute lymphadenitis of the face and neck?
6.
Specify the indications for surgical treatment of acute lymphadenitis.
Tests
1.
The main function of the lymph nodes
a.) platelet synthesis
b)
collection and transportation of lymph
c)
neutralization of microbes and toxins
d)
pumping lymph
d)
lymph formation
2.
There was an error in the classification of lymphadenitis
a)
acute serous
b)
acute purulent
c)
subacute
d)
chronic hyperplastic
d)
chronic aggravated
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3.
Behind the ear, parotid, buccal, mandibular, submandibular
jaw nodes are lymph nodes of the maxillofacial area
a) true b) false
4.
For acute serous lymphadenitis, surgical treatment for
is included in
a) removing the causative tooth b) making an incision
5.
In case of acute purulent lymphadenitis, surgical treatment for
is included in
a)
removal of the causative tooth) a) and b).
b)
making an incision
6.
A complication of acute lymphadenitis is
a) osteophlegmon
b) adenophlegmon
7.
Acute purulent lymphadenitis must be differentiated from
a)
acute sialadenitis
b)
acute periostitis
8.
Acute purulent lymphadenitis must be differentiated from a) odontogenic abscess) acute periodontitis
9.
The treatment complex for acute lymphadenitis includes
a)
X-ray therapy
b)
antibiotic therapy
c)
antihistamine therapy
10.
The treatment complex for acute lymphadenitis includes
a)
physiotherapy
b)
detoxification therapy
c)
restorative therapy
Situational tasks
Task 1. The patient was diagnosed with abscessing lymphadenitis of the submandibular region on the left.
1.
What pathological processes could predispose
What are the main factors in the development of lymphadenitis?
2.
Make a plan for examination and treatment.
Task 2. The patient went to the dental clinic about an exacerbation of chronic periodontitis of tooth 34. An
examination in the submental region revealed a round infiltrate, 3 cm in diameter, with clear boundaries,
painful, not fused to the jaw, in the center of which fluctuation was detected. The skin over the infiltrate is
hyperemic and tense.
1.
Make a diagnosis.
2.
Make a treatment plan.
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Topic 21. Chronic lymphadenitis. Clinic, diagnosis, differential diagnosis, treatment.
Manifestations of HIV infection in the maxillofacial area
Place of class - Hospital. Department of maxillofacial surgery. Lesson duration - 180 min. Purpose of the
lesson
1.
Study the clinic, diagnosis, differential diagnosis of chronic lymphadenitis of the maxillofacial area.
2.
Study methods of treatment of chronic lymphadenitis of the face and neck.
Based on the nature of the course of the disease, two forms of chronic lymphadenitis can be distinguished chronic productive and chronic abscessive lymphadenitis.
Chronic lymphadenitis is characterized by hyperplasia of lymphoid elements, which is accompanied by an
increase in the size of the lymph node. Over time, lymphoid tissue is replaced by connective tissue.
Abscesses with a well-defined connective tissue capsule can form in the thickness of the lymph node.
With chronic productive lymphadenitis, the disease often begins gradually. Patients indicate that 2-3 months
or more ago they developed a painful “ball” that gradually increased. In other cases, the disease is wavy in
nature. During the next exacerbation, the lymph node enlarges. When the inflammatory phenomena subside,
it decreases, but does not reach its original size.
The general condition of patients with productive lymphadenitis is usually satisfactory. During the
examination, a dense, mobile formation is detected according to the location of a particular group of lymph
nodes. It is often possible to identify the primary source of infection.
Chronic productive lymphadenitis must be differentiated from:
1)
specific damage to the lymph nodes in actinomycosis, tuberculosis, syphilis;
2)
dermoid and branchiogenic cysts;
3)
benign tumors;
4)
primary malignant tumors of lymph nodes and metastases in them.
To clarify the nature of the damage to the lymph node, immunodiagnostic and radioisotope diagnostic
methods are used. The final diagnosis is made on the basis of microscopic examination of material obtained
by biopsy or puncture.
Chronic abscessing lymphadenitis is the outcome of chronic productive lymphadenitis. Clinically, the
affected lymph node is detected in the form of a painful ovoid-shaped formation, densely
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elastic consistency. Being a constant source of infection, it often causes malaise and decreased performance.
Under the influence of exogenous and endogenous factors, an exacerbation of chronic focal infection occurs
with the development of periadenitis and adenophlegmon
Treatment. Patients with chronic lymphadenitis need a thorough examination in order to identify and
eliminate the primary source of infection.
In case of chronic productive lymphadenitis, measures are taken aimed at increasing the general
immunological reactivity of the body and activating immunological processes in the area of the lesion:
vitamin therapy, autohemotherapy, general ultraviolet irradiation, the use of UHF and microwave, iodine
electrophoresis, lidase. If conservative measures are ineffective, the lymph node is removed. Without a
preliminary attempt at conservative treatment, sharply enlarged and long-existing lymph nodes are removed.
In patients with chronic abscessing lymphadenitis outside the acute phase, it is advisable to remove the
affected node. During an exacerbation, opening of the abscess is indicated. In the postoperative period,
general strengthening treatment and physiotherapy are prescribed.
Manifestations of HIV infection in the maxillofacial area
HIV infection is a human infectious disease characterized by the development of immunodeficiency and
subsequent opportunistic infections. HIV infection is not an independent disease, but is a complex of
symptoms.
Characteristic symptoms of HIV infection in the maxillofacial area are:
1.
Lymphadenopathy, which is manifested by an increase in all lymph nodes of the face and neck,
primarily the occipital ones.
2.
Candidiasis, which manifests itself in the form of ulcerative filmy candidia and goat, erythematosis,
histoplasmosis.
3.
Leukoplakia.
4.
Gingival-periodontal changes.
5.
Stomatitis.
6.
Xerostomia.
7.
Neoplastic diseases such as Kaposi's sarcama and squamous cell carcinoma of the oral cavity.
Knowledge of the symptoms of HIV infection in the oral cavity will allow the dentist to make a preliminary
diagnosis, take the necessary preventive measures and refer the patient for examination.
105