POST OPERATIVE

EMERGENCY MANAGEMENT IN
PERIODONTICS
• The most significant complication or emergency occur in PERIODONTAL
THERAPY are
• 1. SHOCK, SYNCOPE
• 2. HEMORRHAGE
• 3. PAIN
• 4. SWELLING, HEMATOMA
• 5. DELAYED HEALING
• 6. ALLERGIC REACTIONS TO DRESSING
• 7. SENSITIVITY OF THE TEETH

SHOCK :-
- The most serious of all complication is anaphylactic shock to
an administride drug.
- it is life threatening state, which require immediate attention.
 CLINICAL MANIFESTATIONS:-

• - It usually develops with in about one half hour following

administration of drug.
- The patient feels uneasy, difficulty in
breathing, nausea, becomes pall, then cynotic, perspiry
heavily and collapse.
- The blood pressure becomes very low and
the pulse flast and weak or it may be felt at all. Respiration
becomes asthmatic.
 MANAGEMENT:-
- The assistant should be introduced to call emergency service
whenever it is suspected that the patient is going into
shock.
- Place the patient in trendelen burg´s position, clear the air
passages and administer oxygen.
- If the blood pressure is very low, give 0.5 ml. epinephrine
(1:1000 injectable form) intramuscularly, preferably in the
tongue muscles.
- It may be given in any large muscle.
- Do not inject epinephrine subcutaneouly, that may, it is
absorbed very slowly.
- If the patient`s heart has stopped completely, emergency
external heart massage should be introduced, if the
breathing has also stopped, artificial respiration should be
given until emergency help arrives.
- All the personnel in the dental office should recive training
periodically in cardiopulmonary resuscitation (CPR)
produces so that they can assume an active role in an
emergency situation.
- If the patient shows signs of agitation and chest
pain, oxygen should be administered and the
emergency service called, since these symptoms
may indicate a heart attack. Administration of
epinephrine would be contraindicated for such
patient.
-
 OTHER CAUSES
- Of shock like symptoms may be hypoglycemia of insuline
shock in diabetes.
- Individual with hypoglycemia may require a suger
containing beverage prior to and during periodontal
surgery.
- Shock may also be the result of loss of blood. Internal
hemorrhage or cardiovascular accidents. The most
important action in any shock like reaction are called in
emergency help immediately and to adminiter supportive
emergency therapy.
 SYNCOPE:-
- The most common cause of loss of
consciousness in the dental chair is simple
syncope.
- The situation is unpleasant and embrassing
to the patient and disruptive to the treatment
procedures.
 MANAGEMENT :-
- If the patient starts to become abnormally pale perspire heavily and is
restless, place the chair in horizontal position with the head below the
level of the body.
- If the pulse become noticeable weaker than normal, record the blood
pressure.
- Aromatic ammonia may help to prevent syncope.
- If the patient is in deep syncope and making slow recovery, oxygen
should be administered.
- While the patient is regaining consciousness, he should be kept in
horizontal position and should not be allowed to sit up until his normal
color has returned and is fully recovered from a feeling of dizziness
and nausea.
 PRECAUTION :-
- The patient fears through psychological and
pharmacological preparation before the
surgery.
- Instruments and blood should be kept
outside the patient`s field of vision.
 HEMORRHAGE:-
- Because periodontal surgery ordinarily reverse only small
blood vessels, significant hemorrhage is not a frequent
complication of periodontal surgery when local anesthetics
and vasoconstrictor drugs are used.
- Average amount of blood loss during one session of
periodontal surgery has been reported to be 37ml.
- Periodontal surgery has usually been ruled out during the
treatment planning for the patient while bleeding disorders.
 CAUSES:-
- Bleeding disorders for instance.
- Heavy intake of aspirin or the other drugs after the
systemic and hygienic phase of treatment.
- Abnormal bleeding may be related to unexpected on set of
menstrual period.
- There may also be accidental severing of large blood
vessels during surgery ,provoking extensive bleeding.
 Hemorrhage

Primary Intermediate Secondary

 PRIMARY:-
- Primary postoperative hemorrhage starts at
the time of surgery.
 INTERMEDIATE:-
- Intermediate hemorrhage starts soon after the
surgery, after having stopped temporarily
following surgery.
- It is due to break down of incomplete clot, such as
associated with loss of vasoconstrictor effect of
anesthesia.
 SECONDARY:-
- The secondary type post surgical
hemorrhage may starts from 24 hours to 10
days postoperatively. The patient should be
instructed to contact the dentist, who did the
surgery immediately if intermediate or
secondary hemorrhage occurs.
 MANAGEMENT
• First to reassure the Patient and control the
patient’s emotional concern about the bleeding .
• A mild oozing type of bleeding can usually be
controlled by a pressure pack , using gauze
moistened in sterile saline solution and held firmly
in position for 2-3 minutes . Injection of LA along
with 1:50,000 vasoconstrictor drug may also be
helpful in controlling bleeding
• If the bleeding is arterial spouting of light red
blood as may be seen with encroachment on the
palatal anterior , one may try to crush the cut
artery with a hemostat. Hold the hemostat in
position for several minutes and remove it
carefully . If there is not enough soft tissue to
grasp the hemostat one may attempt to seal the
vessel by crushing the bone of nutrient bone
channel . If the cut are surface is in soft tissue,
cautery may be tried either by a hot instrument or
a ball electrode from an electrosurgical machine.
• If the bleeding is severe, it may have to be stopped by
tying a suture around the bleeding vessel.
• A slow , oozing , venous bleeding (dark blood) may be
stopped by the use of Gelfom or oxygel.
• These preparation are somewhat irritating and definitely
have to be removed before a periodontal dressing is placed
over the wound.
• The placement of periodontal dressing helps to stop
bleeding , and there is no need to have an absolutely dry
surgical field with complete stoppage of all bleeding , prior
to the placement of dressing.
• The patient should never be allowed to leave the
dentist office until all gross hemorrhaging has
stopped.
• If intermediate or secondary hemorrhage occurs ,
administration of local anesthetic with
vasoconstrictor centrally to the wound is
recommended . The remove periodontal dressing,
clean and inspect the wound and treat the bleeding
similarly to a primary type of bleeding .
 PAIN
During the first 24 hours following the periodontal surgery ,
there should be only minimal pain and discomfort if the
basic principles of atraumatic surgery were absorbed
carefully.
CAUSES
- Mechanical trauma during surgery.
- Drying the bone
- Traumatic bone surgery or incorrectly placed periodontal
dressing
- A very common source of post operative pain is
impingement from the post surgical dressing .
– Management
– The surgical area should be anesthetized , the dressing
removed and the cause of pain is identified .
– When the cause has been eliminated a new carefully fitted
dressing should be placed in to the position.
– The dressing that is placed inter proximally should be soft ,
so that it can cover the wound without pressure
– After the dressing has been changed the patient may be given
pain relieving medication, however medication usually for
few days
• INFECTION
• Usually does not start until 2-4 days following surgery.
• Such pain is usually accompanied by lymphadenopathy and there may
be slight elevation in temperature
• If do not treated promptly , the lymph adenopathy and the elevation in
temperature will increase
• The patient should be examined, the temperature recorded and the
periodontal dressing removed .
• If the temperature is no significantly elevated and the teeth are not
noticeable sour to percussion , place a topical antibiotic ointment (eg.
3% achromycin) over the wound and apply a new dressing .
• The patient should be introduced to take his temperature is
significantly elevated or the teeth in the area of the surgery are
noticeably sour to percussion .
• The patient should be placed on systemic
antibiotic therapy. Fever and soreness of the teeth
to percussion may indicate a developing
osteomyelitis and the patient should be treated
with large doses of antibiotics, preferably
PENICILLIN .
• Doubling the normal dosage for atleast 10- 14
days is recommended for osteomyelitis .s
 Periodontal surgery

Exposure of part of alveolar process.

Periodontal surgery
Severe trauma to
the bone or heavy direct pressure
on the bone
from the periodontal dressing

Development of bare bone

Resorption of necrotic bone by inflammatory process.

Sequestrem formation
• During this time the area should be kept covered by a
periodontal dressing to minimize the infection and
discomfort.
• The chance of bare bone developing is much greater
following gingivectomy with electrosurgery . If excessive
granulation tissue develops as a result of poorly fitting
periodontal dressing or loss of the dressing shortly after
surgery , the granulation tissue should removed with sharp
instrument . A well fitting periodontal dressing then should
be placed over the wound and left for one week.
 REACTION TO PERIODONTAL
DRESSING
• Allergic reaction to periodontal dressing some times occur
especially in patient who have been wearing dressing over
a prolonged period of time due to multiple epixodes of
surgery or delayed healing.
• The sensitivity reaction is usually provobed by the eugenol
in zinc oxide eugenol type of dressing.
• It has been observed , although very rarely with
noneugenol containing dressing.
• First symptom of a sensitivity reaction to periodontal
dressing is a burning sensation in the buccal mucosa and
on the surface of the tongue where contact with dressing
occur.
• The patient should be told at time of the surgery of the possibility of such
symptom occurring and instructed to contact the dentist on experiencing
them.
• If the dressing is not removed , the reactionm progress from erythema to
vesicle formation and edema ( which is especially in relation to the
tongue ) may be serious complication, since epiglottal edema interfere with
air passage.
• If the patient is not treated a generalized allergic reaction may develop ,
including a dermatitis and the patient may become seriously ill .
• It is therefore very important that the surgical dressing be removed
completely as soon as any of the initial symptoms of allergic reaction
appear .
• If a new dressing is needed a non eugenol- containing type of dressing,
such as coe-pack or peripak may be used .
• The patient should also be given systemic
antihistamines for at least 4-5 days inorder to
intercept the allergic reaction.
• With severe allergic reaction, the patient may have
to be hospitalized and given cortison therapy .
• Type of treatment should be the responsibility of a
qualified physician rather than of dentist .
SENSITIVITY OF THE TEETH
• The root surface of the teeth that have been
exposed to the oral environment as a result
of periodontal surgery sometimes become
extremely sensitive to heat and cold , as
well as to mechanical and chemical stimuli.
 MANAGEMENT
• Optimal post surgical plaque control this
sensitivity usually abates over a few weeks or
month occasionally it may resist over aq long
period of time .
• A large number of procedure and medicaments
have been recommended for treating such
sensitivity , however none is spectacularly
effective .
• Tooth paste for reduction of sensitivity
provide varying degrees of relief for long
term sensitivity .
• Topical fluoride application are often used .
• Combining fluorides and electrical has been
claimed to reduce sensitivity , but the
reduction apparently is not dependent on
the use of electric current.
• Iortophoretic devices and denifries for root
hypersensitivity should be prescribed as
possible means of reducing discomfort.
• Vigorous plaque control in the most
significant factor in long term reduction of
sensitivity , unless the sensitivity is related
to occlusal dysfunction , which requires the
oral therapy.