OS Sheet #13 By Luma Al-Najada

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Number of lecture: the last one of the first semester.
Lecturer: Dr. Hazem Al-Ahmad.
Done by: Luma Al-Najada.

Management of hospitalized patients
Dentists should be aware of the protocols of the hospitals, because there are cases we’ll face in which we have to hospitalize patients like immunocompromised patients, patients with severe medical problems you’re not very confident that you can manage the problem in the dental office like patient with uncontrolled cardiac problems ( atrial fibrillation or history of recent angina … etc.) and you have to do an emergency dental treatment and you’re not really happy about your emergency equipments in dental practice so you can go for the hospital atmosphere. There are many hospitals with the full dental clinic and full dental setup; you have an anesthetist with a team who are ready to help in these procedures.
Here we’re not talking about maxillofacial surgeons’ procedures like cleft palate, we mean here dentists in general who treat for example : patients need fillings or simple extraction under severe medical problem so we might need to go to hospital to treat him , behavioral managements like pediatrics; good number of cases you might need to have dental treatment under general anesthesia for children and therefor you have to be aware of the hospital setup and this commonly seen because many families have uncooperative children so we prefer to go to hospital for treatment , and also patients who have mental problems even though if they are older than pediatric patients sometimes it’s not easy to manage them in dental practice so you might go to the hospital , also there’s a lot of people who give you consultations for the hospital; some hospitals have resident dentists so they can refer the case to him but other hospitals send consultations to dental office out of the hospital for example if they have patient who has open heart surgery tomorrow and he has mobile anterior teeth this make the anesthetist afraid and worried if they will give him general anesthesia, because they put oral tube so they might cause extrusion or fracture of the teeth so this make medical problem and for this they want to take consultation before the surgery from the dentist .
Emergency room consultation ; sometimes there’s a patient in emergency room after a road traffic accident , he has generalized trauma or general injuries , including dental trauma like fracture, loss of teeth, extrusion, retrusion so they might need the help from a dentist to evaluate the case and give the advice.
So we talked about the main procedures which need hospitalization like behavioral management, children, mental retardation, mental problems, and patients who need sedation or general anesthesia like wisdom teeth patients, apicectomy, multiple implants, bone grafting, and many procedures that can’t be done appropriately in the dental practice.
We have to know what is called Day surgery; which means that we don’t need to hospitalize the patients the day before the surgery and make him undergoing GA, instead we let the patient come in the same day of the operation and make to him assessment and then we start our minor dental procedure and then he gets discharged in the evening at the same day, its full useful for the dentists.
Wikipedia: Outpatient surgery, also known as ambulatory surgery, same-day surgery or day surgery, is surgery that does not require an overnight hospital stay. The term “outpatient” arises from the fact that surgery patients may go home and do not need an overnight hospital bed. The purpose of outpatient surgery is to keep hospital costs down [citation needed], as well as saving the patient time that would otherwise be wasted in the hospital.
How do we prepare our patient to the admitted hospital?
Imagine that you are in your clinic and we have patient should be admitted to hospital for a reason, there are main steps that we should follow.
If we have patient who wants to undergo elective surgery always admission should be 24 hours before the operation , we take the medical history in clinic with full assessment , if the patient need any investigation for patient who will undergo GA like CBC test ; CBC has many benefits one of them it measures the hemoglobin which should not be less than 10, if it’s less then we don’t do elective procedures because hemoglobin is a carrier for oxygen and therefore we’ll have some ischemia to the cardiac muscles due to lack of oxygen which carried usually by hemoglobin therefore its very essential to have an acceptable level of hemoglobin for general anesthesia , and by the CBC test we can know the platelets count which is very important to know if there is bleeding tendency or not , we can know also differential or white blood cells count , sometimes we take differential with CBC because it give us the different percentages of WBC if the patient have Neutrophilia, Neutrocytosis, or other kind of WBC increase this is useful as also indicators whether the patient have infections or viral infection or bacterial .. etc. Most of patients who undergo GA at least as a baseline record we need CBC, if the patient his age is above 50 usually we take chest x ray in order to know the width of the heart if there’s is enlargement or hypertrophy its indicated Heart failure or congestive heart failure or left sided heart failure, it’s a baseline record for patients who is above 50 and sometimes we need ECG.
So it depends on the procedure, for example patient with severe cellulitis or abscess you might think about culture, sensitivity, aspiration…etc. we have many types of investigations hematological,biochemical,microbiological, radiological (panorama,CT scan,MRI), we take the investigations in level according to be in certain condition. The most important thing that in the clinic we prepare all these things before the operation time so therefor we prepare investigations and then we Inform consent.
Informed consent is very essential in medical practice and dental practice, it’s a printed paper we have to fill it with informations , and all the procedures we are going to do and all the possible complications; if we want to remove three wisdom teeth we have to write three, its illegally that we write three and then we extract four and we have already made the patient signed for only three teeth , legally it not acceptable .
We should fill it also with complications; for example we’re going to extract wisdom teeth we should write about complications like parasthesia of tongue, Lips and all the possibility.
In the other hand we shouldn’t panic the patient as if we tell him that you’re going to die in this operation , everyone has the possibility to die during the operations but it depends on the percentage, for example the mortality rate for the fitted healthy person is less than 0.00001% or 0 .000001% its very low, so you have to know that the patient has the right to know every complications but also he is usually anxious, scared from the operation and has certain psychological condition so we shouldn’t make them panic and tell them the extreme complications, so we should be very careful about the informed consent. According to the inform consent the age of patient should be above 18 , if he is less than 18, then an adult family member above 18 should be with him.
We should evaluate the anxiety too to decide to go for sedation, GA, or to give premedication (midazolam) that relief the anxiety before the operation.
All patients who will undergo GA should be fasting for at least four hours, some dentists prefer 6 or 8 or 10 hours, in order to avoid vomiting during giving anesthesia, if he has food in the stomach and vomit it he might aspirate the food contents and then go to the lungs and cause severe problems. So patients shouldn’t eat or drink 6 to 8 hours at least before the operation.
Premeditations are of two types; drugs that the patients already took for example for hypertension, diabetes! And the antibiotics, prophylaxis, pain killers, and steroids according to the procedures we talked about last time.

Here the doctor started to talk about a story for one of his patients ……
Let’s go through a story of one of my patients , how we admitted her to hospital to do the necessary procedure , here we didn’t care about the exact procedure but just to make the story more interesting , how we admit patients ? What procedures we do? How we prepare her?. The dr asked: what do you think Sara has?
She is a very young girl she was four or five years old at that time before six years, she presented with limited mouth opening not more than 5 mm with severe facial asymmetry and chin deviation to the right side , according to the CT scan (section in the mandible ) the patient has fracture on the left side , on the other side there is ossification between the condylar head and the glenoid fossa which we call it tempromandibular joint ankylosis , so she has fusion between condylar head and glenoid fossa causing ankylosis and therefore limitation in the mouth opening , so she can’t eat and open her mouth properly, she is underweight, and its life threatening; for example if vomiting and aspiration happened to her it might be very dangerous , and it affects growth as we can see the asymmetry because condyle contributes to the growth site and she doesn’t have the normal movement of the mandible and therefore no stimulation of the functional matrix area . She has growth of one side of the mandible more than the affected side so all what we need to do is resection of the TMJ ankylosis or release of this fusion in order to allow for further treatment.
We admitted Sara to the hospital, We took CT scan and assessment she is medically fitted healthy, as Sara has limited mouth opening so we suspect that there is problem in the air way therefore we should consult the anesthetist to see if they can enter the tube nasally or not . So we should prepare our self before the operation, we have to think about all possible complications that might happen during the procedures.

Operating room protocols; there is special protocol we should follow it. first thing we should have assistants because nurses in the hospitals they don’t know the dental instruments especially if we are going to do something specialized like amalgam filling so you should take your assistant with you .
also in the operations there are scrub nurse and circulating nurse ; scrub nurse is the one who is wearing gloves and mask and gowned , and the other nurse which is the one who helps in giving sterilized instruments (like the assistants in -2) ,these scrubbed and circulating nurses are to avoid cross infection and to get the ideal atmosphere.
We decide before the operation if it is local with sedation or day case surgery or GA with admission, also we should prepare all the instruments.
The uniform in the surgeries always are the same for all of the working team; it’s the scrub or the normal dress (cap and trousers). The person who is wearing the scrub and mask and the cap is not allowed to touch any of the sterilized instruments, he is just an observer, and the one who is wearing gowned and gloves and mask, he is allowed to touch the instruments and the patient.
We talked before that we should decide the intubation whether it is nasally or orally and we decide this according to the case; for example if I’ll make filling on the right side then we should put the tube on the left side orally. If the size of the surgery was huge in the oral cavity or the patient has limited mouth opening so we put the tube nasally . If the patient has mandible fracture we should put the tube NASALLY because we look for the occlusion because the main problem with the mandible fracture is the change in the occlusion, there is malocclusion, we can’t get back the occlusion normal if the tube is orally.
Length of procedure is important, if it’s too long we should always put something called Foley’s catheter (urinary catheter) to monitor the fluid output of the patient, if the operation will take more than four hours we should put the catheter, we protect the eyes also.
we do something called scrubbing painting and drapping ; scrubbing means that we bring special gauze and we clean the operative site of the patients and then we apply a certain disinfectants ( iodine, stablon ) , and then we drape the patient it means to cover the patient with towels, and then we apply a moist throat pack (to put very long gauze in the throat) it closes all the oropharynx to prevent aspiration while we are working on the patient and we should make sure its removed after the final procedure (by the anesthetist).

Getting back to Sara, she was admitted and necessary investigation and CT scan was taken , and we did surgical plan then we decide to do extra oral incisional release of ankylosis , as we can see we scrubbed the area and then we painted iodine dye and then we cover everything but the operative field, we just expose the area of operation , then we apply the markers by the marker pen in order not to make large incision because it is an esthetic incision .
We talked before that the surgeon wear the surgical scrub uniform, the shoe cover, and the cap. Usually there is a side room beside the operation room in order to clean the hands with stablon or iodine (basically we need 4-5 minutes to clean the hands and the forearms), and putting on your gowned and masks and cloves and then get inside the operating room.
Postoperatively, remember always to write down your orders, what types of food should the patients drink, eat, what medications he needs to take home (antibiotics, painkillers, mouth washes). General care of the patient and the operating site if it’s necessary to put gauze or dressing or antiseptic.
Intermaxillary fixation (IMF ) ; its very important if we end the operation and the patients has IMF , we should be very careful that the patient should have one to one nurse to patient ratio in his room, because these patients may suffer from depression, cardiovascular respiratory system problem and by the presence of IMF they might undergo air respiratory depression, so we tell the nurse if at any instance the patient vomits or difficulty in breathing happened the nurse have to cut the IMF . Previously we used this method a lot, but now we rarely use it with the utilization of fixation method and screws and plates.

Wikipedia: Intermaxillary fixation is a procedure for stabilizing broken bones and allowing them to grow together in the proper position, involves breaking the bones in a controlled way and then resetting them into correct positions. After the bone is set (a process called "reduction") a period of fixation ensures proper healing. Oral and maxillofacial surgeons use it by binding the jaw shut with wires or elastic bands.
Note : Some people use IMF to try to do weight reduction, we don’t advice these people to do this because they may have tendency for vomiting which is very dangerous if the jaws are sticking together.
Question asked by student if we have to refer all the patients after the operation to the ICU, the dr answered that there’s difference between recovery and ICU; all patients should be refer to the recovery room to make sure that everything is okay (oxygen, vital signs .. etc.), but referring to the ICU depends on the case if our patient needs special care, if the patient has cardiac problem we should refer him to the CCU.
Postoperative pain control and sedation we make sure we cover our patient by analgesia or pain killers, we usually give pre-op analgesia by injections (voltaren, non-steroidals). Make sure to write the postoperative notes, like if the patient has a surgery we expect pain postoperatively, so we make sure it’s all written and cover.
Postoperatively, the oral hygiene we all know how to give instructions about it. Wound care, if there’s dressing so we put topical antibiotic, stretches removal after 1 week or five days. Diet instructions, during the operations the patients take IV fluids, after the procedures if its minor procedures we can encourage the patient to start normal diet soon, if the patient has certain precautions we can go ahead with the non-oral diet, for example patient has operation for cleft and we need the oral hygiene to be very clean and no contamination occurs we can keep the patient on IV fluids for two to three days according to the condition.
Postoperative complications, there are some common complications that might happen after GA whatever the procedures is , many patients for example suffering from throat discomfort , air way obstruction, laryngeal edema, that’s why previously dentists tend to do GA in the dental clinic, It’s so dangerous to give GA in the dental clinic.
If the patient has nausea and vomiting we give him antiemetic drugs (stemetil). Wire cutters (for patients have IMF ) should be available with the patient in case of complications.
If the patient has fever we should make sure that we cover the patient with antibiotic like paracetamols, vlotaren… etc. if the patient still has fever while he is hospitalization we shouldn’t discharge him.
Fluids; usually the daily intake should be two to three liters, we give usually combination dextrose and normal saline and the lactate ringers solution, by them we usually try to accelerate as much as possible the normal range of electrolytes of the body, but we should be aware not to give the patient these fluids on long period of time in order not to disrupt the normal electrolytes range of the body.
Blood transfusion is important to think about if we expect long procedure or if its relatively big surgery (cancer, orthodontic surgery), the normal protocols in JUH that the patient relatives should give 2 units of blood before the operation. Autogenous blood transfusion( it’s not here in Jordan, in Europe) it means that the patient has elective surgery after and he give himself give 2 units of blood six months before the procedures in order not to have transmitted disease.


Good Luck 