CHAPTER 41. Oral/Maxillofacial/Dental Care
Denise O’Brien
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe anatomy and physiology of oral cavity pertinent to the patient undergoing oral and maxillofacial procedures.
2. Identify assessment parameters for patients undergoing oral and maxillofacial operative procedures.
3. Define nursing care priorities in each postanesthesia phase.
4. Describe patient education after oral and maxillofacial procedures related to diet, pain management, oral care, activity, and follow-up.
I. OVERVIEW
A. Care of the oral or maxillofacial surgical patient presents many challenges.
1. Patients may experience feelings of suffocation.
a. Procedure may prevent normal breathing patterns (inability to breathe through mouth and/or nose).
2. Continuous reassurance and explanations assist the patients in understanding they are not in any danger.
3. Astute assessment skills are necessary.
a. Compromise of the airway can occur at any time.
b. Immediate corrective actions needed
II. ANATOMY AND PHYSIOLOGY
A. Mouth and oral cavity include the following structures:
1. Lips, teeth, gums, buccal mucosa, tongue, palate (hard and soft), tonsils, pharynx, temporomandibular joints (TMJs) (Figure 41-1)
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| FIGURE 41-1 ▪ The oral cavity. (From Massler M, Schour I: Atlas of the mouth in health and disease, 1958, by permission of the American Dental Association, Chicago.) |
B. Oral cavity is bounded by the jawbones and associated structures (muscles and mucosa) (Figures 41-2 and 41-3).
1. Includes
a. Cheek
b. Palate
c. Oral mucosa
d. Glands whose ducts open into the cavity
e. Teeth
f. Tongue
2. Except for the teeth, interior of mouth covered with mucous membrane, lined with salivary glands
a. Secrete saliva
b. Aid in first step of food digestion
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| FIGURE 41-2 ▪ The skull, anterior view. (From Ferraro JW: Fundamentals of maxillofacial surgery, New York, 1997, Springer-Verlag.) |
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| FIGURE 41-3 ▪ Lateral view of the skull. (From Ferraro JW: Fundamentals of maxillofacial surgery, New York, 1997, Springer-Verlag.) |
C. Oral cavity forms beginning of the digestive system
1. Chewing occurs.
2. Site of the organs of taste
3. Mouth is entrance to the body for food, occasionally air.
4. Major organ of speech and emotional expression
D. Associated structures
1. Buccal: pertaining to or directed toward the cheek
2. Tooth:
a. Hard calcified structure set in the alveolar processes of the mandible and maxilla
b. Mastication of food
3. Gingiva: mucous membrane (the gum) surrounding the teeth
a. Covers the tooth-bearing border of the jaw
b. Overlies crowns of unerupted teeth
c. Encircles the necks of erupted teeth
d. Supporting structure for subjacent tissues
4. Mandible:
a. Horseshoe-shaped bone forming the lower jaw
b. Largest and strongest bone of the face
c. Articulates with skull at TMJs
5. Maxilla
a. Irregularly shaped bone that forms the upper jaw
b. Two identically shaped bones that are considered one
(1) Assists in the formation of the floor of the orbits, part of the lateral walls and floor of the nasal cavity, and the palate; contains the maxillary sinuses and tear ducts, which drain into the nasal cavity
(2) Supports the upper teeth
c. Described as the architectural key of the face; touches all facial bones, including the mandible, through the contact of upper and lower teeth
6. Palate—the roof of the mouth consists of:
a. Hard palate
(1) The rigid anterior portion
(2) Formed by the maxillae and the palatine bones
(3) Covered by mucous membrane
(4) Forms a bony partition between the oral and nasal cavities
(5) Hinged to the soft palate
b. Soft palate
(1) Posterior, fleshy part of the palate
(2) Arch-shaped muscular partition between the oropharynx and nasopharynx
(3) Lined by mucous membrane
(4) Flanked by tonsils
(5) Uvula is in the middle of the soft palate—a fleshy projection pointing down to the tongue.
(a) Forms seal posteriorly with the pharynx to help direct food to the esophagus and air to the trachea
(b) Critical to the development of normal speech patterns
7. Tongue
a. Movable muscular organ on the floor of the mouth
b. Accessory structure of the digestive system
c. Composed of skeletal muscle covered with mucous membrane
d. Location of organs of taste
e. Aids in chewing, swallowing (deglutition), cleansing tooth surfaces, and the articulation of sound (phonetics)
8. Nerves (Figure 41-4)
a. Sensation supplied to upper teeth and gingival by
(1) Maxillary division of the trigeminal nerve (cranial nerve V)
(a) Posterior superior alveolar
(b) Middle superior alveolar
(c) Anterior superior alveolar
b. Mandibular division gives off
(1) Lingual nerve (sensation of anterior two thirds of tongue, the floor of mouth, gums)
(2) Inferior alveolar nerve (sensation of premolar, molar teeth of mandible)
(3) Mental nerve (sensation of the lower lip and chin)
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| FIGURE 41-4 ▪ The trigeminal nerve (cranial nerve V). (From Ferraro JW: Fundamentals of maxillofacial surgery, New York, 1997, Springer-Verlag.) |
9. TMJ: bicondylar joint formed by
a. Head of the mandible
b. Mandibular fossa
c. Articular tubercle of the temporal bone
III PREANESTHESIA ASSESSMENT AND PARAMETERS SPECIFIC TO PROCEDURES
A. Examination
1. Inspection and palpation of greatest use
a. Head and neck
(1) General appearance
(2) Facial appearance
(3) Trismus (limited degree of mouth opening)
(4) Neck lumps
(5) Gross facial swelling
(6) Skin color and texture
b. Intraoral
(1) Tongue: size, mobility, color, and texture
(2) Oral mucosa (palate, cheeks, labial mucosa, floor of mouth): examination for changes in color, texture, ulcers, lumps
(3) Alveolar ridges and gingivae: color, texture, gingival recession, ulcers, and lumps
(4) Teeth: number, position, restorations, crowns, caries, cracked, mobile and missing teeth, exposed structure
B. Increased risk associated with history or need to alter perioperative management
1. Cardiac: may require antibiotic prophylaxis
a. Endocarditis
b. Heart transplant
c. Valve implants
2. Implants: antibiotic prophylaxis may be needed
a. Joints (major replacements)
b. Grafts of artificial materials
3. Coagulation and bleeding disorders
a. Factor VIII deficiency (hemophilia)
b. Von Willebrand’s disease: following may be given just before procedure begins:
(1) Factor VIII
(2) Synthetic factor VIII
(3) Aminocaproic acid (EACA [Epsilon-aminocaproic acid] or Amicar)
(4) DDVAP (desmopressin acetate)
c. Anticoagulant therapy
(1) Coagulation testing may be required (prothrombin, partial thromboplastin time, platelet count) to determine coagulation status before proceeding with elective surgery.
4. Immunocompromised patient or immune disorders
a. Human immunodeficiency virus, acquired immunodeficiency syndrome
b. Patient with history of organ transplant
c. Universal precautions should be used with every patient.
d. Immunocompromised patient may require special care (isolation, scheduling, altered medication regimen).
5. Patients with cancer receiving radiation therapy to the head and neck region
a. Decreased salivary flow secondary to salivary gland atrophy requires saliva substitutes and aggressive anticaries management with
(1) Custom trays
(2) Topical fluoride applications
(3) Immaculate oral hygiene
b. Extractions usually completed before initiation of therapy to decrease the risk of development of osteoradionecrosis
(1) Debilitating complication
(a) Leaves a patient with painful exposed bone in the oral cavity
(b) Can progress to
(i) Pathological fractures
(ii) Recurrent infections
(iii) Raining sinus tracks
c. Hyperbaric oxygen treatment is indicated for surgical procedures if previous radiation dose totals >4500 cGy. (This is still used in some centers but has fallen out of favor because of poor efficacy and lack of literature supporting a benefit.)
6. Trauma
a. Edema present
(1) Recent injury
(2) May delay operative repair until edema diminishes
b. Disfigurement: may be significant and emotionally disturbing to patient and others
7. Chronic pain
a. Pain tolerance alterations
b. Chronic analgesic use may alter postoperative analgesic management.
8. Nutritional status changes
a. Difficulty chewing, swallowing
b. Pain may interfere with ability to eat and meet caloric demands and nutritional requirements.
9. Developmentally challenged
a. Potential behavioral problems (combative, disruptive, abusive)
b. Legal authorization appropriately obtained before treatment commences
C. Airway status evaluation
1. Evaluation of airway for ease of intubation in oral or maxillofacial surgery
a. Mobility of the neck—ability to touch chin to chest and each shoulder; flex and extend
b. Position of the trachea relative to the mandible—distance from thyroid cartilage to anterior bony chin; at least 6.5 cm acceptable
c. Ability of the patient to open the mouth—at least 3.6 cm in adults desirable
d. Structures visualized when the patient opens the mouth and vocalizes “ahh…”—see the uvula and surrounding pharyngeal structures.
D. Determine the educational needs of patient and caregiver.
1. Oral care, analgesia, preoperative anxiety
2. Discharge planning
IV INTRAOPERATIVE PRIORITIES
A. Anesthesia choice: fit of the teeth is one of the best templates a surgeon can use to restore the original form of patient’s face.
1. General
a. Nasal intubation desired for unobstructed visualization of orofacial structures
b. Allows reconstruction of the upper and lower jaws to be guided by the patient’s occlusion
2. Sedation and analgesia with local anesthesia
a. Midazolam, ketamine (glycopyrrolate to decrease oral secretions)
(1) Less risk of respiratory depression
(2) Reduced emergence delirium after ketamine with midazolam
b. Benzodiazepine with fentanyl
(1) Oxygen recommended when used with local anesthesia
(2) May use methohexital or propofol for additional sedation
3. Local anesthesia used alone for minor oral procedures or used as an adjunct during general anesthesia
a. Minimizes immediate postoperative pain
b. Minimizes bleeding in operative field
c. Helps separate tissue planes to ease dissection
d. Allows for less anesthetic agent because of reduced surgical stimulus
B. Intraoperative concerns
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1. Hemostasis and intraoral bleeding
a. Hemostatic agent may be used.
b. Gelfoam, Surgicel, Avitene, topical thrombin, bone wax (for bone bleeders), Tisseel (fibrin sealant)
2. Airway
a. Loss of reflexes with excessive sedation
b. Positioning of endotracheal tube, potential displacement
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