Shock Management in Prosthodontics

ABSTRACT

Shock is a condition in which circulation fails to meet the nutritional needs of the cells and at the same time fails to remove the metabolic waste products.

Prosthodontics is a branch, it trains us to deal with various kinds of patients. Sometimes we face very special patients , namely critical patients. Comatose and severely ill patients suffer a multiple number of difficulties. Their oral care is paramount importance because they are dependent on their family and attendants. A Prosthodontist is often sought after to manage these patients. One’s knowledge and clinical skills are utilized here to prepare adequate appliances for them .These appliances are made with ease and provide oral hygiene for these special patients. The call of the hour for the Prosthodontist is to understand and develop a determination to treat such patients successfully.

Key words: Adrenaline, allergens, anaphylaxis, lignocaine.

INTRODUCTION:STAGES OF SHOCK

Divided into 3 stage :

1. Early, "compensated shock".
2. Progressive, "decompensated shock".
3. Irreversible shock.1

Classification of Shock:

1. Hypovolemic shock or Haematogenic shock.
2. Cardiogenic shock.
3. Traumatic shock
4. Neurogenic shock
5. Psychogenic shock
6. Septic shock
7. Miscellaneous types

• Anaphylactic shock.
• Insulin shock.1,2

Among all types of shock, Anaphylactic shock is one, most of the dentists facing while practicing .Anaphylaxis is defined as “an acute, potentially life-threatening hypersensitivity reaction, involving the release of mediators from mast-cells, basophils and recruited inflammatory cells. Anaphylaxis is defined by a number of signs and symptoms, alone or in combination, which occur within minutes, or up to a few hours, after exposure to a provoking agent. It can be mild, moderate to severe, or severe. Most cases are mild but any anaphylaxis has the potential to become life-threatening” (World Allergy Organization). Anaphylaxis develops rapidly, usually reaching peak severity within 5-30 min, and may, rarely, last for several days. All dental practitioners should be aware of the diagnosis and management of emergencies such as anaphylaxis that may arise from the use of local anesthetic agents in their clinical set up. Resuscitative drugs such as antihistamine, adrenaline and corticosteroids should be available at chair side for immediate use. All patients must be warned prior to local anesthetic agent administration of the possible danger that follows its use. They should be told to report back immediately to the clinic if a rash should develop.3 Anaphylaxis may develop immediately and is usually immediately life-threatening due to respiratory embarrassment. Early symptoms and signs include a sensation of warmth, itching especially in the axilla and groin, and a feeling of anxiety and panic. These may progress into an erythematous or urticarial rash, edema of the face and neck, bronchospasm and laryngeal edema.

PROBLEMS FACING IN PROSTHODONTICS

The neurophysiology of jaw movement in the comatose patient is the basis for the design of an intraoral prosthesis3.which prevents discoordinate or neuropathologic mandibular chewing movements and facilitates healing of pre-existing lesions4. Neuropathological chewing in hospitalized, comatose patients can occur from severe brain damage following a closed head injury, hypoxia, and septic shock5. Also ruminatory reflex chewing activities in the comatose patient and the associated prostheses used in their treatment have been well documented in the literature6. Trauma to oral soft tissues in comatose patients may be more widespread than reported, as no extensive study of this problem has been conducted. Various appliances for the prevention of self-inflicted injuries to oral tissues particularly in children and the physically and mentally challenged have been documented, but there is little information on their use in adult comatose patients. Because comatose patients lack cerebral control of the masticatory cycle, they can easily injure themselves. Although it is not uncommon for patients with a decreased level of consciousness and in need of intensive care to be restrained to prevent injury due to involuntary movement of the limbs, head and neck restraint is often difficult and may be dangerous to the patient2.

APPLIANCES/METHODS

They are occlusal bite planes, mouth props, Padded tongue blades, intermaxillary fixation, mandibular - cast silver caps with acrylic bite-blocks, stock fluoride trays, tongue guards / mouth guards and a modified retainer. Occlusal bite planes are removable dental appliances carefully molded to fit the upper or lower arch of teeth. These bite planes are typically made of heat-cured acrylic resin. Soft acrylic or light cured composite, or vinyl splints may be made more quickly and cheaply, but are not durable, and hence indicated for short-term use. Soft splints are preferred in children to accommodate growth changes.Thy are used to correct an anterior crossbite7. Mouth Props are made of non elastic foam such as polyurethane, foamed polyethylene, foamed epoxy which help in retaining the mouth open.The block or prop is made with different cross sectional dimensions so that the desired mouth opening can be achieved without fatigue to the jaw muscles. When the teeth indent into the foam plastic material, the block is locked in place against any slippage and is disposable after use8.They help prevent injury to the patient should the jaws suddenly be clenched.These might be easily dislocated in the mouth and should be securely attached to a length of dental floss for quick removal to prevent their aspiration by the patient . Padded tongue blades are made by wrapping adhesive tape around tongue depressor blades. It is mostly used by health care providers during oral examination and while maintaining oral hygiene.It acts as a lever when it is used to correct anterior crossbite7. Intermaxillary fixation using arch wires in combination with hard acrylic devices was used to prevent neuropathologic chewing. This was more of a surgical management, at times painful for the patient and could not be removed immediately in case of emergency. If the wire or rigid plastic components break they create jagged, virtually nondetectable foreign bodies which could be aspirated into the lungs. These may also lacerate the throat, larynx or soft tissue of the oral cavity8.To ensure comfort and prevent aspiration, it is advisable to tape either a scissors or a wire cutter, and a hemostat to the bed for rapid removal of elastic or wire traction in case of vomiting.Use of a soft toothbrush and the water-pik gives very satisfactory results during intermaxillary fixation8. Stock fluoride trays were useful as an initial or interim device in the case of hospitalized unconscious paediatric patients with uncoordinated mandibular movements or clenching. U-shaped oral appliance is formed from acrylic resin material.Typically, this is about 3mm in thickness, although other thicknesses can be used. The appliance has a generally U-shaped body formed by an extra-oral leg and an intra-oral leg and a centrally curved contour in between the two. A periodic change of appliance position is desirable to prevent chronic soreness and cutting of the mouth. This was not possible with the prosthesis units used before. This appliance gives the feasibility of being easily switched from side-to-side which prevents excessive irritation to the corner of the mouth. This also prevents unilateral compression to the teeth and their supporting structures. Its insertion and removal is simple, therefore it can be easily used by either medically skilled or unskilled attendants of the patient9 . Mouth guard/protector –Although the protective benefits from the use of mouth protectors alone cannot be separated from the combined use of the face guard and mouth protector, the value of the latter in reducing tooth injuries can at least be implied.There are three general types:-stock/readymade, those formed directly in the mouth, custom made from a cast of the maxillary dental arch. Conventional mouth guard is made using acrylic with adequate coverage of teeth to ensure good retention, but at the same time not overly extended to avoid impingement on soft tissue and muscle attachment. A long flexible handle made of stainless steel wire is attached to the anterior portion of the mouthguard4.This could be secured to the patient’s hospital gown with a safety pin to prevent accidental loss or possible inhalation of the appliance. The labial portion of the appliance is slightly thickened (8 mm) by layering to prevent the lips from becoming trapped between the anterior teeth. The appliance can be kept in the mouth at all times except when removed for daily oral hygiene procedures. The practice had been to construct either a full coverage mouthguard or one covering the anterior sextant using traditional materials; however, these materials lack proper adaptation to the dentition, hence were not adequately retained. Dislodgement of earlier appliances may cause even more serious complications if it is inhaled. It can be modified to make it, a simple unilateral arch appliance of acrylic. This design, which covered two-thirds of the mandibular occlusal surface, is preferred only for short term. In the long term, a full arch stent would be more appropriate to prevent an imbalance to the occlusion and inadvertent overeruption of teeth not covered by a partial appliance.

PROGNOSIS/POSSIBLE COMPLICATION

Without proper treatment anaphylaxis can be deadly. However, most people who receive proper treatment do well. Try to avoid substances that caused the reaction. Drugs classified as beta-blockers, monoamine oxidase inhibitors, angiotensin-converting enzyme inhibitors may make anaphylaxis worse or interfere with treatment. If the patient is having a history of anaphylaxis, check with the physician to find-out if the patient is having one of these medications.10