2012 F
FACULTAD DE MEDICINA ESCUELA DE ODONTOLOGÍA
PROTOCOLO : EXODONCIA SIMPLE
carlos paco
Carlos Alberto Paco Vilchez
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FACULTAD DE MEDICINA
ESCUELA DE ODONTOLOGÍA ODONTOLOGÍA DEPARTAMENTO DE CIRUGÍA BUCO MÁXILO FACIAL
PROTOCOLO: EXODONCIA SIMPLE
Autor
: CD Carlos Alberto Paco Vilchez
Colaboradores
: Esp. CD. Fredy Gutierrez Ventura Esp. CD. Jaime Huamaní Parra Mg. CD Marco Antonio Puccinelli Wang
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2
Agradecimientos: Al Mg CD Marco Antonio Puccinelli Director de la Escuela de Odontología USAT Al Esp. CD Fredy Gutierrez Ventura Cirujano Máxilo Facial UPCH, profesor invitado Al Esp. CD Jaime Huamaní Parra Cirujano Máxilo Facial UPCH, profesor invitado
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3
Dedicatoria: A mi padre Jacinto Paco y a mi madre María Vilchez por darme la vida y su apoyo constante A mi esposa Martha Chávez por su paciencia y apoyo A mi hija Angelina Carolina por su apoyo apoyo moral
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4
DEFINICIÓN: Exodoncia
simple
es
el
procedimiento
quirúrgico bucal que se lleva a cabo con más frecuencia es desgraciadamente, desgraciadamente, la extracción dentaria. La exodoncia es una maniobra cuyo fin es separar estos elementos,
desgarrando
el
periodonto
en
su
totalidad.
Frecuentemente para conseguir luxar y extraer el diente deberemos distender y dilatar el alvéolo a expensas de la elasticidad del hueso. La exodoncia ideal es la extirpación total del diente o de la raíz dentaria sin dolor y con el mínimo daño de los tejidos circundantes.
INDICACIONES 1.-Dientes uni o multirradiculares completamente erupcionados. 2.-Remanentes radiculares. 3.-Dientes con patología infecciosa. i nfecciosa. 4.-Dientes con patología periodontal. 4.-Exodoncia por motivos ortodóncicos. 6.-Exodoncia por motivos estéticos. 7.-Anomalías de erupción. 8.-Motivos socioeconómicos. socioeconómicos.
Para ello debemos seguir los l os siguientes pasos:
Antes de la cirugía o pre – operatorio: 1.
El paciente paciente debe ser examinado examinado por por un profesor asignar el caso al alumno.
antes de
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5
General cuando el paciente requiere 3 o más dientes para exodoncia, la cual debe ser revisada y firmada por un profesor.
3.
Si el paciente refiere de una enfermedad sistémica: endocarditis bacteriana,
hipertensión
arterial,
discrasias
sanguíneas,
diabetes, infecciones renales, se realizará las interconsultas interconsultas a la especialidad respectiva.
4.
Si
se
sospecha
de
problemas
cardíacos,
portador
de
marcapaso, daño renal, daño hepático, discrasia sanguínea solicitar RIESGO QUIRÚRGICO.
5.
En caso de hemofilia u otras discrasias sanguíneas realizar la cirugía en un centro hospitalario con un equipo multidsciplinario: anestesiólogo, anestesiólogo, hematólogo, odontólogo, enfermera, auxiliares.
6.
Las interconsultas y las solicitudes de exámenes auxiliares debe ser autorizada y firmada por el profesor.
7.
Interpretar
los informes informes de los exámenes exámenes auxiliares: sangre,
orina, supervisado supervisado y firmado por el profesor.
8.
Si el paciente NO PRESENTA ninguna enfermedad obviar los pasos de los números 3 al 7.
9.
Tomar una radiografía peri apical del diente a extraer (foto 1); si el paciente requiere 3 o más exodoncias tomar una radiografía panorámica. El alumno debe realizar el informe radiográfico supervisado y firmado por el profesor.
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6
10. Presentar el caso clínico a los profesores del Departamento de Cirugía Oral y Maxilofacial. (Usar historia clínica física, radiografías peri apicales y panorámicas). Si el caso clínico es aprobado será firmado y autorizado. Para presentar el caso clínico tener en cuenta lo siguiente:
-
En la historia clínica deben estar resumido lo siguiente : o
Anamnesis:
Filiación.
Enfermedad actual.
Cuestionario
de
salud
sobre
odontológicos y médicos.
o
Resumen del cuestionario de salud.
Examen clínico general:
Ectoscopía:
Apreciación general.
Facies.
Grado de colaboración.
Peso y talla.
Funciones vitales:
Temperatura.
Presión arterial.
Frecuencia cardiaca.
Frecuencia respiratoria.
antecedentes
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7
o
o
Locomotor.
Sistema nervioso.
Examen clínico estomatológico extra oral:
Forma de cráneo.
Forma de cara.
Simetría facial.
Perfil anteroposterior.
Perfil vertical.
Musculatura.
Fonación.
Deglución.
Respiración.
Otros hábitos.
ATM.
Ganglios.
Examen clínico estomatológico intra oral:
Labios.
Vestíbulos.
Frenillo.
Paladar duro.
Paladar blando.
Orofaringe.
Lengua.
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8
Tejidos blandos.
Tejidos duros.
o
Plan de trabajo para el diagnóstico definitivo.
o
Informe de exámenes auxiliares.
o
Diagnóstico Definitivo:
Del estado general.
Del estado estomatológico:
Tejidos blandos.
Tejidos duros.
o
Alternativas de tratamiento y presupuesto.
o
Programación de citas.
o
Tratamiento y evolución: en cada cita debe anotarse el tratamiento, el avance o el control y debe ser supervisada y firmada por el docente.
11. Si el caso clínico es aprobado será firmado y autorizado. 12. El paciente debe firmar la hoja de consentimiento del tratamiento (foto 2).
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9
13. Un día antes el alumno esteriliza sus instrumentos y ropa quirúrgica (foto 3).
Foto 3.Instrumentos y ropa qjuirúrgica qjuirúrgica estériles es tériles
14. Si el paciente es un menor de edad debe acudir acompañado de sus padres que autoricen el tratamiento.
15. El día de la cirugía, el paciente viene en ayunas y acompañado de un familiar (foto 4).
Foto 4.-
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10
Retirarse toda alhaja, arete, anillo, chaquira, reloj, celular, etc. (foto 5 y 6).
Foto 5.Retirándose la chaquira c haquira de la mano
Foto 6.Retirándose el collar
las mujeres amarrarse el cabello con collete ( foto 7)
Foto 7.Cabello amarrado y sujetado con collete
El alumno Ingresa a la clínica con gorro, mascarilla, pantalón y
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11
Lavarse las manos con jabón germicida y colocarse guantes descartables (foto 9), cambiar la botella de la unidad con suero fisiológico (foto 10).
Foto 9.Colocándose guantes descartables
Foto 10.Cambiando la botella con suero fisiológico. fisiológico.
Limpiar y desinfectar la unidad dental con alcohol al 95% (fotos 11, 12, 13 y 14), colocar la lámpara en la angulación adecuada a la posición del diente a extraer: o
Maxilar superior: la lámpara va de arriba hacia abajo y adelante hacia atrás.
o
Maxilar inferior: la lámpara va de arriba hacia abajo y de
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12
Foto 12.Desinfección Desinfección de la lámpara dental.
Foto 13.Desinfección Desinfección del Cabezal del sillón
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13
Limpia y desinfecta la manguera de succión con alcohol 95º (foto 15).
Foto15.Desinfectando la manguera de succión
Limpia y desinfecta la mesa de la unidad dental con alcohol l 95º (foto 16).
Foto 16.Desinfectando la mesa de la unidad dental
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14
Limpia y desinfecta la mesa de mayo m ayo con alcohol l 95º (foto 18).
Foto 18.Limpiando y desinfectando la mesa de mayo.
Colocar en un vaso descartable 5 cc de clorhexidina al 2% (foto 19).
Foto 19.Dispensando clorhexidina al 2% en un vaso descartable
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15
Frotar 10 veces las caras caras ventrales ventrales de ambas manos (foto 21).
Foto 21.Lavando con jabón jabón la cara ventral de las manos
Frotar 10 veces
las caras internas (interdigitales) de los
dedos de la mano izquierda y derecha ( foto 22).
Foto 22.Lavando con jabón jabón las áreas interdigitales de las manos.
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16
Foto 24.Lavandocon jabón el dedo pulgar de la mano derecha.
4to dispensado de jabón
Frotar 10 veces veces la cara dorsal dorsal de la mano izquierda (foto 25).
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17
Foto 27.Escobilla desinfectado con glutaraldehido o alcohol yodado
Foto 28.Retirando la escobilla de la riñonera
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18
Foto 30.Lavando las uñas de la mano izquierda con escobilla y jabón
7mo dispensado del jabón (a la escobilla)
Frotar 10 veces con una escobilla y jabón las uñas de la mano derecha (foto 31).
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19
9no dispensado de jabón
Frotar 10 veces la cara dorsal dorsal del antebrazo antebrazo izquierdo (foto 33).
Foto 33.Lavando la cara dorsal del antebrazo izquierdo
10mo dispensado de jabón
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20
Enjuagarse sin tocar la llave de agua (solo con codo o pie) o el ayudante debe abrir el grifo; juntar los dedos y empezar a lavarse las uñas, luego los dedos (moverlos para que salga el jabón), después continuar con la mano derecha (foto 36). Una vez enjuagado mantener los dedos juntos hacia arriba.
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21
Foto 38.Enjuagando la mano izquierda, observe que la mano derecha siempre para con los dedos hacia arriba
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22
Foto 41.Descubriendo la toalla estéril
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El cirujano 1 descarta la tolla usada en el papel kraft. El cirujano 2 tiene que usar otra toalla estéril (foto 44).
Foto 44.Descartando la toalla
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24
Foto 47.Abriendo y extendiendo el papel externo
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El ayudante o circulante ayuda a colocar el mandilón al cirujano (fotos 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62 y 63).
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Después de colocarse el mandilón se coloca guantes quirúrgicos, El
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El cirujano 1 coge un extremo de la cubierta interna y expone los
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El cirujano 1 estira hacia atrás el guante derecho hasta que los
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61
Retirar el poncho quirúrgico
Limpiar la cara del paciente con suero fisiológico y después con agua oxigenada.
Nunca permitir que un alumno u otra persona se acerque sin gorro, mascarilla y guantes (foto 155).
Foto 155.No permitir que ninguna persona ingrese sin uniforme de cirugía.
Después de la cirugía:
Medicar al paciente con los siguientes fármacos: o
Si está infectado usar un antibiótico y una AINES
o
Si no hay infección usar solo AINES
Antibiótico: o
Fenoximetilpenicilina o penicilina V. - Nombre comercial: Adultos: Megacilina oral 1’000,000 UI tabletas,
- Dosis: 01 tabl c/8h por 7 días.
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62
- Dosis: 25-50 25-50 mg/Kg/día mg/Kg/día c/6h por 7 días.
Amoxicilina
o
-Nombres comerciales: amoxil. Adultos: - 500 mg cápsulas, cápsulas , 01 capsula c/8 horas por 7 días. - 1 gr tabletas, tabletas, 01 tabl c/12 h por 7 días. - 500 mg ampolla, 01 ampolla c/8 h por 7 días
Niños: - 250, 500 mg /5ml suspensión 40 mg/Kg/día c/8 horas por 7 días - 250 mg ampolla, 01 amp c/8h por 7 días
Clindamicina
o
Nombre comercial: dalacin c. Adultos:
300 mg mg cápsulas 01 capsula c/6 horas por 7 días
150 mg/ml ampolla , 01 amp c/6 horas por 7 días Niños:
75 mg/5 ml suspensión, 15- 40 mg /Kg/día c/6 h
En alérgicos a penicilina
Anti-inflamatorio: o
Aflamax, Apronax 550 mg tabletas, 01 tableta c/12 h x 1 o 2 días
o
Dolocordralán extra forte (Diclofenaco sódico 50 mg, Paracetamol 500 mg) tabletas, 01 tableta
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63
o
Ketorolaco 10, 30 mg tableta, 01 tableta antes de dormir y otra al levantarse.(c/8h) levantarse.(c/8h)
o
Acetaminofén (paracetamol) 500 mg tabletas, 01 tableta c/4h x 1 día.
o
Dexametasona 8mg tabl o IM 1hora antes de la cirugía en caso de cirugía ósea (osteotomía). ( osteotomía).
Anotar y explicar las indicaciones post-quirúrgicas al paciente y su acompañante: o
Colocar
el
nombre
genérico
del
medicamento,
su
concentración, su presentación, presentación, y su dosis. o
Morder gasa media hora.
o
No escupir, dejar que la saliva caiga y secarse suavemente.
o
Llegando a su casa realizar 03 aplicaciones de hielo seco sobre la cara en relación a la herida, durante 20 minutos con intervalos de 10 minutos.
o
Dieta líquida 24 horas.
o
Dieta blanda desde el 2do al 5to día.
o
Realizar enjuagatorios con clorhexidina al 0.12% después de cada comida muy suavemente. No hacer buches las primeras 48 horas.
o
No levantar pesos.
o
No exponerse al sol ni al fuego de la cocina.
o
No comidas picantes ni condimentadas.
o
Reposo absoluto 24 horas.
o
Si hay sangrado o dolor comunicarse con su dentista.
o
Anotar su número telefónico.
o
Cita 24 horas.
Descartar las agujas agujas dentales, hojas de bisturí y agujas de sutura en un recipiente de vidrio con contenido de hipoclorito de sodio.
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64
Desinfectar sus instrumentos con detergente enzimático por 15 minutos.
Lavar y secar
Colocar en la caja metálica, envolver con papel kraft y rotular, esterilizar en autoclave
Lavar sus ropas quirúrgicas con detergente, secar, envolver en doble papel kraft y esterilizar en autoclave.
18. Controles post-quirúrgicos:
Los controles del paciente deben ser a las 24 horas, 3 días dí as y 7 días,
observar la herida si no está infectada lavar con suero fisiológico; si está infectada lavar con agua oxigenada, limpiar con gasa, eliminar detritus (fotos 156, 157, 158 y 159) y medicar con un antibiótico bactericida. Si se rompió un punto esperar la cicatrización por segunda intención (foto 160) .
Foto 156.Lavando con suero fisiológico
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65
Foto 158.Gasa después de limpiar la herida.
Foto 159.Herida limpia.
Foto 160.Punto suelto, cortar con tijera y esperar cicatrización por segunda intención
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66
A los 7 días verificar el estado de la herida, si la evolución es buena se retiran retiran los puntos; para retirar los puntos lavar con 10 cc cc de suero fisiológico con una jeringa descartable descartable con aguja. Para retirar los puntos, coger con una pinza portalgodón o una pinza Adson el extremo del punto, colocar la punta de la tijera para retirar puntos u otra afín por debajo y a un costado del nudo, cortar el nudo, y colocarlo en una gasa; retirar sucesivamente los puntos.
Después de retirado los puntos el paciente puede ingerir sus alimentos sin restricciones.
