GUIDELINES

Individual work of students

During preparation for Practical classes

Educational discipline Surgical stomatology

Module № 2 Inflammatory diseases in maxillofacial region.

Content module № 4 Nonodontogenous inflammatory diseases in

maxillofacial region

Theme lesson

Complication of inflammatory diseases of jaw-

facial region. Thrombophlebitis of facial veins and

vessels of hard brain-tunic. Clinical picture,

diagnostics, medical treatment. Features of motion

and medical treatment of inflammatory diseases of

jaw-facial region at patients which suffer by

diabetes mellitus, and also at the elderly and

gerontal patients.

Course 3

Faculty Stomatological

Poltava 2018

MINISTRY OF HEALTH OF UKRAINE

Ukrainian medical stomatological academy

“Approved”

On the meeting chair

Of Propaedeutics Surgical Stomatology

The Head of the Department

prof. Novikov V.M. ___________

“ ____ ” _____________ 20 ____

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1. Actuality of the topic:

For today the problem of treatment and prophylaxis of complications of

inflammatory diseases of maxillofacial region is very actual. It is caused, first of all,

by ascending of quantity of patients with inflammatory diseases, gravity of flow and

gravity of treatment of such complication as a thrombophlebitis of facial veins.

The knowledge of an etiology, pathogeny, clinic, diagnostics and treatment of

the basic complications of inflammatory processes oral surgery is very necessary for

the future doctor - the stomatologist.

The diabetes mellitus sharply worsens a course of acute purulent process

maxillary - facial region and his prognosis. Interaction of an acute purulent infection

with diabetes mellitus forms a vicious circle of the phenomena arising at it. Decrease

of protective defense reactions of a old organism, including immune is wear erring of

compensatory - adaptive properties introduces essential difference in a clinical course

of inflammatory process. Changes of memory, violence of psychics, drop of

sensitivity at patients of old age complicates revealing of clinical manifestation of

illness.

2. The objectives of the studies:

To have the common representations about a state of a problem of a

thrombophlebitis of facial veins and vessels of a firm meninx.

To familiarize with features of an etiopathogenesis, clinic, diagnostics, modern

methods of treatment and principles of an operative measure at thrombophlebites of

facial veins and vessels of a firm meninx.

To be able to collect an anamnesis of life and disease of the patient, to make a

diagnosis, to define a treatment planning at thrombophlebites of facial veins and

vessels of a firm meninx.

To define places of this complication among inflammatory diseases of a

maxillofacial region in practice of the surgeon - the stomatologist.

To have general knowledge about features of ethiopathogenesis, clinics,

diagnosis flow and manifestation of inflammatory diseases of maxillofacial region in

patients of with a diabetes mellitus and old age and senile.

То understand, memorize and use the received knowledge.

To be able to diagnose purulent - an incendiary pathology in persons of patients

of senile and old age with a diabetes mellitus. To carry out complex,

ethiopathogenetic treatment.

3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary

integration).

Name of previous

courses

These skills

Anatomy A structure of vessels of a maxillofacial region

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Operative surgery and

topographical anatomy

Topography of sinuses of a firm meninx of the brain;

blood supply of the person.

Pathophysilogy An etiology and a pathogenisis of inflammatory processes

oral surgery

Communicable diseases Agents which produce inflammatory processes oral

surgery.

4. Tasks for independent work in preparation for the classes.

4.1. A list of key terms, parameters, characteristics that must learn the

student in preparation for the lesson:

Term Definition

Phlebitis is an inflammation of a vein

Thrombophlebitis is phlebitis (vein inflammation) related to a thrombus (blood

clot)

4.2. Theoretical questions to lesson:

1. To define a thrombophlebitis.

2. Classification of a thrombophlebitis of facial veins.

3. An etiopathogenesis of a thrombophlebitis of the person.

4. Signs of a thrombophlebitis of the person.

5. Complication of a thrombophlebitis of facial veins.

6. Signs of a thrombophlebitis of veins of a firm meninx.

7. Differential diagnostics of a thrombophlebitis of veins of the person and a

cavernous sinus with other complications of inflammatory processes maxillary - facial

region.

8. Principles of treatment of complications of inflammatory processes maxillary

- facial region.

9. Prophylaxis of complications of inflammatory diseases maxillary - facial

region.

10. Features of a clinical course of purulent - inflammatory diseases at persons of

old and senile age.

11. Features of diagnostics and treatment of purulent - inflammatory processes in

patients on the background of a diabetes mellitus.

12. Prophylaxis of common and local complications during treatment.

4.3. Practical works (tasks) are performed in class:

- To carry out observations of he patient with a thrombophlebitis of facial

veins;

- To carry out differential diagnostics of a thrombophlebitis of facial veins with

other diseases maxillary- facial region;

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- To make a of planning treatment of the patient with a thrombophlebitis of

facial veins.

To carry out observation of the old patient with incendiary disease maxillofacial

regiment which suffers diabetes mellitus?

- To familiarize with technique of disclosing of abscesses at patients of old age;

- To make a treatment planning of sick old age with incendiary disease.

5. Theme contents:

The thrombophlebitis - inflammations of a vein with its thrombosis thrombosis,

is complication various pyodermatitis (a furuncle, an carbuncle), an acute odontogenic

infection contamination or inflammatory diseases of a nose and its additional sinuses.

A thrombophlebitis - polyetiological and nonspecific complication in which

development the key role is carried out with infringement of a hemodynamics and

infringement of a sedimentation of a blood under conditions of a lesion of a wall of

vessels which passes on a background of drop of a reactivity of an organism,

irrespective of a kind of the originator.

Classification

1. On localization of the initial locus: odontogenic non odontogenic;

On type of clinical flow:

1. Acute;

2. Subacute;

By the form the originator of the disease:

1. staphylococcal;

2. Streptococcal;

3. Combined and so forth.

On gravity of flow:

1. Average;

2. Serious;

3. The extremely serious;

On depth of a lesion of veins:

1.endoflebitis;

2. A periphlebitis;

3. A phlebitis;

4. A thrombophlebitis.

Site of entry at a thrombosis of facial veins are the struck tissues of the face and

a neck.

The initial focus - a region of an inflammation which arises on a place of

penetration of an infection contamination and is further a source of originating of a

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thrombophlebitis of facial veins of a neck. Damage of an outward wall of a vein by

inflammatory process results from its diffusion with series the posed initial locus that

results in a periphlebitis. Then in process all vascular wall is involved; in it the

bleeding is slowed down; under influence of having process of an inflammation of a

tissue, the structure of a blood change and rate of its sedimentation raises. In a vein

the thrombus is formed.

In a pathogenesis of a thrombophlebitis of facial veins the big role presence of a

rich grid of lymphatic and venous vessels of the person with numerous anastomoses

plays, connection of veins of the person, a nasal cavity, pterygopalatine fossas with

veins of an orbit, a cavernous sinus; and also drop of a reactivity of an organism after

the transferred catarrhal diseases, microbic allergy and autoallergy, mechanical

damage of a skin.

In particular, dangerous localizations of the initial locus are:

1. A upper lip;

2. A septum and wings of a nose;

3. A lower lip and a chin;

4. Eyelids.

Symptomatology of a thrombophlebitis of facial veins:

1. A feverishness;

2. A tachycardia;

3. During angle, or a facial vein appear morbid "tension bar" of infiltrate tissue;

4. A hyperemia of the person with a cyanotic shade;

5. Diffusion of an edema far for borders of an infiltrate;

6. Dilating hypodermic veins;

7. A leucocytosis with alteration to the left;

8. High erythrocyte sedimentation rate (ESR);

9. Reduction of time of a sedimentation of a venous blood, rising of the

maintenance of Fibrinogenum in a blood.

Serious complication of a thrombophlebitis of facial veins is the thrombosis of

a cavernous sinus which carry to intracranial to complications as the thrombosis of a

cavernous sinus is complication of a thrombophlebitis of the person also the state of

the patient at a thrombosis of veins of the person worsens:

1. Sharp headaches; a loss of consciousness;

2. The ptosis educes; exophthalmos; at a pyesis of a thrombus - abscess formation

and development of a septicopyemia;

3. Pronounced cyanosis a mucosa of labiums, a skin of a nose, ears that testifies to

an intoxication of an organism and infringement of activity of cardiovascular

system.

The second complication of a thrombophlebitis of facial veins is development

of an abscess of a brain, which meets at phlegmons more often:

А) pterygopalatine fossas;

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B) An infratemporal fossa;

C) Temporal region.

The diagnosis of a thrombophlebitis is make on the basis:

1. Assessments of an anamnesis of disease;

2. Complaints of the patient;

3. The data of clinical examination;

4. The big value has research of settling system of a blood of the patient:

manifestation of signs of a hypercoagulation; ascending of a level of

fibrinogenum; drop of fibrinolytic activity of a blood.

Thrombosiss of veins of the face and cavernous sine frequently have transitional flow

as quickly (sometimes immediately) are complicated a sepsis, a meningitis, a

meningoancephalitis, an abscess of a brain. Therefore the thrombosis of a cavernous

sine is necessary for differentiating from such complications:

1. pararhinal sinusitises;

2. A periostitis of an orbit;

3. A subperiosteal abscess;

4. A reactive edema of an orbit;

5. exophthalmos;

6. Restriction of mobility of an eyeball.

Periostitis and subperiosteal abscess of an orbit

Signs are more expressed: the edema is distributed to environmental tissues,

sometimes motility of an eye globe circumscribed, vision is broken.

Treatment: well-timed, complex.

1. A sanitation of the initial locus of an inflammation and extraction causal

tooth; disclosing of a phlegmon, a sinusotomy at empyema maxillaris sinuses,

disclosing of the purulent - necrotic locus at a furuncle or a carbuncle.

2. In dependence on the agent, character and diffusion of the initial locus of an

inflammation and a reactivity of an organism, with the count of the given

bacteriological, biochemical and immunological researches it is appointed:

Antibacterial,

- disintoxication,

Anti-inflammatory,

- immunopotentiating,

- hyposensitizatiating,

Symptomatic medicamental therapy.

3. With the purpose of struggle against a thrombosis use:

- Anticoagulants,

- Thrombolytic remedy,

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- Preparations which improve microcirculation and reduce aggregation of uniform

elements of a blood.

4. If necessary, in cases of abscess formation of infiltrate, operative disclosing

the focus of an inflammation is necessary for the length of a vein, with the

subsequent drainage of a wound; sometimes resort to a dissecting away

thrombosed veins.

Graphical frame of a theme

Initial purulent An endophlebitis A periphlebitis of the locus

An abscess of a brain

Thrombophlebitis

Facial veins A sepsis

A meningitis

A meningocephalitis

Convalescence A lethal outcome

Diabetes mellitus is a disease in which does not produce or properly use

insulin. Insulin is a hormone that is needed to convert sugar, starches and other food

into energy needed for daily life. The cause of diabetes mellitus continues to be a

mystery, although both genetics and environmental factors such as obesity and lack of

exercise appear to play roles.

Diabetes mellitus in basis of which absolute or relative failure of insulin lays is

wide-spread disease.

It is necessary to emphasize, that anabolic Hormone the insulin provides first of

all recycling of a glucose, assists a biosynthesis of proteins, glycogen and Adepses.

Acting on membranes insulin sensitive tissues, the insulin, as a matter of fact, is the

active participant of a metabolism.

S.G. Genes considers, that the cause of downstroke of body resistance of

patients with diabetes mellitus to an infection contamination is not only a high level

of Saccharin in blood, but also the common attrition, a hypovitaminosis and violence

of all metabolic processes with violence of function of a liver.

It is important to emphasize, that patients with a diabetes mellitus frequently suffer a

tuberculosis, pustule lesions of a skin, a furunculous. Probably, the cause of it is

raising deduction of Saccharin in a blood which frames congenial medium for

development of bacteria.

Acute inflammatory process for the definite time enhances diabolism, produces

augmentation of an acidosis and need of insulin for an organism. The carbohydrate

metabolism sharply rises. At acute purulent process preconditions for destruction both

endogen, and an exogenous insulin which defines development of a decompensation

of diabetes mellitus.

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The augmentation of a course of diabetes mellitus worsens development of acute

purulent process of maxillofacial region and its prognosis. To wide use of insulin,

antibiotics, Sulfanilamide’s abscess, a phlegmon, an osteomyelitis and even furuncle

in patients with a diabetes mellitus frequently cause death from (40-90 %).

The clinic of acute purulent disease of maxillofacial region at patients with

diabetes mellitus in many respects depends on gravity of a basic disease.

At diabetes mellitus I of a stage (deduction of Saccharin in a blood on an empty

stomach does not exceed 7,7 mmol/l, that is 140 mg/%) the beginning of development

of acute purulent process of maxillofacial region differs a little from such at

practically healthy people.

At a diabetes mellitus of II stage (quantity of Saccharin in a blood on an empty

stomach is smaller 12,2 mmol/l or 220 mg/%) and in particular III stages (deduction

of Saccharin the maximum 12,2 mmol/l, or 220 mg/%) purulent process proceeds

roughly with the increasing of to upper 39 being accompanied by acute pain

sensations. Quickly there is a morbid infiltrate without precise borders which tend to

spreading. Thus fluctuation is marked not always. The infiltrate arises in one

anatomical region, but in 1-2 days in process involve the next cellular spaces,

sometimes from the opposite side. Frequently inflammatory process extends to an

neck. Poured course of disease regard as a result of sharp downstroke of immune

forces of an organism and its resistibility of the infection. Attributes of intoxication

early occur (a headache, general weakness, a hyperthermia, a tachycardia).

Analysis’s of the blood and urine testify to, glucosuria, ketonuria. In the blood

substantial growth of quantity of leucocytes with alteration of the formula to the left is

marked, erythrocyte sedimentation rate (ESR) raises till 30-60 gg/h. As a result of

toxic action function of kidneys and liver suffers - of proteins contents in a blood

chouger.

At analysis of the clinical and laboratory data the precise interrelation between

gravity of inflammatory process and the level of Saccharin of a blood is found out.

Higher contents of Saccharin, the more serious purulent process proceeds.

Treatment. The majority of authors is adherents of immediate disclosing of a

phlegmon, considering, that any purulent process at any moment can become the

cause of a decompositions of diabetes mellitus and development of a coma. At acute

purulent process the hyperglycemia as proteolytic enzymes destroy exogenous and

endogen insulin, binding it with proteins of Serum which threatens with development

coma.

At a choice of a method an anesthesia the special attention is payed to blockade

stress or reactions as the epinephrine, raising intensity of a glycogenolysis, cause

hyperglycemia. At a choice of a kind the anesthesia is necessarily to take into account

a state of cardiovascular, respiratory systems, internal glands secretion. Medicamental

treatment consists in rational antibacterial therapy, disintoxication therapy stimulating

and fortifying therapy. During all cause of disease it is necessary to supervise

functions of organs and systems.

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The operational trauma and an anesthesia cause a hyperglycemia. In this

connection the special value receives the insulin’s therapy, carried out under the

control of research of Saccharin in the blood.

In connection with violence of function of the liver and a protein metabolism at

long term of inflammatory process there is a necessity to alternate a transfusion of

stored blood with transfusion blood substitutes. Normalization of carbohydrate and

protein metabolism assists attenuation inflammatory process in wounds and its

healing. Term of treatment of phlegmons in the patients burdened by diabetes

mellitus, from 7-10 days up to 1 month and more.

6. Materials for self control:

А. Assignments for self control (tables, charts, drawings, graphs)

Main tasks Recommendations Comment

To seize the

procedure of

examination of the

patient with a

thrombophlebitis of

facial veins

To carry out in such sequence:

1. Outward examination

(symmetry of the face,

integuments, lymphatic system).

2. To survey the face (colour of a

skin, presence of infiltrates,

edemas) to survey ophthalmic

region (exophthalmos, a ptosis).

3. To survey an oral cavity

(presence of an aboriginal

infection contamination - a

periodontitis, a ulitis and so forth).

During examination to reveal

complaints of the patient (the

fever, an edema of the face,

presence of an infiltrate, a

dermahemia and its cyanosis), to

collect anamnesis, to make

laboratory researches remove

systems of a blood.

To pay attention on

clinical signs, which

characterize

thrombophlebites facial

veins and vessels of a

firm meninx.

B. Self-control tests:

1. Paresis of oculomotor cranial nerves is observed at:

А) A furuncle and carbuncle;

B) mediasthenitis;

C) A thrombosis of a cavernous sinus;

D) A noma.

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2. Thrombophlebites of facial veins educe by originating more often:

А) An endophlebitis;

Б) A periphlebitis.

3. The endophlebitis educes at:

А) Transition of inflammatory process from environmental tissues;

B) Drop of a reactivity of an organism;

C) Damage of a vascular wall;

D) The increased coagulability of a blood.

4. The morbid infiltrate as "tension bar" is observed at:

А) An abscess of buccal region;

B) A thrombophlebitis of a facial vein;

C) An abscess of peripharyngeal space;

D) A noma;

F) An carbuncle.

5. At a suppuration of soft tissues of the face the inflammatory process passes to sinus

of a brain on:

А) To anastomoses of facial veins;

B) A facial arteria;

C) To a temporal vein.

C. Tasks for self-control:

1. Patient Р., has addressed to the surgeon - stomatologist with complaints to

deterioration of the common state, a headache, a fervescence up to 38-39°С.

Objectively: the edema of the face, including blepharons, a cyanosis of integuments of

the face without precise borders, by palpation is defined morbid inspissations which

last on a course of veins as tension bar. Define the clinical diagnosis:

А) An erysipilatous inflammation;

B) A Quincke's edema;

C) A thrombosis of facial veins;

D) A furunculosis of the person.

2. To patient P., the preliminary diagnosis was fixed: a thrombophlebitis of facial

veins. Prescribe additional methods examination:

А) The common analysis of a blood;

B) A X-ray examination of bones of the person;

C) A thermography;

D) Ultrasonic research;

F) coagulability blood.

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3. In department maxillofacial surgery patient P., 31 years, with the diagnosis is

hospitalized: an carbuncle of a upper lip at the left, a thrombophlebitis of facial veins.

In a treatment planning necessarily it is necessary to include:

А) A catheterization of an outside carotid artery;

B) Dissection of a pyoinflammatory infiltrate;

V) Antibacterial, anti-inflammatory, disintoxication therapy, anticoagulants, an

artificial diuresis;

G) Antibacterial, anti-inflammatory therapy, procoagulums, an artificial diuresis;

D) Antibacterial, disintoxication therapy, procoagulums.

7. Bibliography.

Basic:

1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis

III, James R.Hupp, Myron Tucker/ 2003, MOSBY, – 776 p.

2. Hupp JR, Williams TP, Vallerand WP: The 5 minute clinical consult for

dental professionals PDA, Baltimore, 2002, Williams & Wilkins

Additional: 1. http://emedicine.medscape.com/article/463256-treatment

Methodical recommendations is prepared by docent Rezvina Ye.Yu.

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Answers: Tests:

1 - V; 2- B; 3 - A; 4-B; 5 - A.

Tasks Answers: 1-V; 2 – A, V, D; 3 – A, B, V.