Coronado Dr. Jose M. Bernardo Physician and Surgeon
Hyperbaric Medical Director, SA
* Our Lady of Pilar Sanatorium
3 rd. Street 10-71 zone 15
01015 - 2279 Tel Guatemala
5000 x 624, 55182472 Emergency
Dr. Luis Angel Hernández
Surgeon Maxillofacial
* Dental Group
Guatemala
9 ª. Calle 2-81 zona 14 01014
- Guatemala
PBX
2367 5929 5600 9132
Emergency
* Our Lady of Pilar Sanatorium
3 rd. Street 10-71 zone 15
01015 - Guatemala
INTRODUCTION GENERAL HISTORICAL
SCIENTIFIC COMMUNITIES CONCEPT OF PHYSIOLOGICAL EFFECTS O2Hb
CELLULAR AND BIOCHEMICAL EFFECT
ANTI-EDEMA EFFECT
IN CHRONIC REFRACTORY OSTEOMYELITIS
EFFECT ON OSTEO-radionecrosis EFFECT ON GRAFT
Summary REFERENCES
INTRODUCTION
Jaw Region and oral health is a constant concern in any individual who seeks to stay healthy. The manifestations of illness dentogingivales, particu-larly those with inflammatory edema, are a frequent complaint, although large facial deformities from odontogenic abscesses and less so in urban areas. In any case, whenever there is an event that alters the system-Natica Estomatog, patient consultation, especially to relieve pain and restore the morphology normal facial. Additionally, all injuries, which involve the facial region are of great concern to patients and professionals, although in severe cases of multiple trauma, are the last to be resolved. At the right time, always made all efforts to rehabilitate the damaged parts of the face. The type of treatment is very important for the restoration of normal function and prevent facial deformity. A modern therapeutic method used in the management of facial trauma caused by different causes (traffic accidents, firearm, a short, aggression, etc.), as well as dental infections severe, refractory osteomyelitis and osteo-radionecrosis, is the use of hyperbaric oxygen therapy (O 2 Hb), with which the results are very effective, improving the speed and quality of healing tissue, shortening recovery time.
The O2Hb is a branch of the Hyperbaric Medicine. Therapeutic use SIVO non-invasive, is based on an increase in the capacity of diffusion and oxygen tension in the plasma. Oxygen breathing 100% pure high ambient pressure conditions, within a tight team called hyperbaric chamber, it generates multiple biochemical effects, physical and physiological positive.
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GENERAL
The Earth's Atmosphere normally exerts a surface pressure of 14.7 pounds per square inch or 760 millimeters of mercury (mmHg.) at sea level, being equivalent to one atmosphere absolute (ATA). This atmosphere we breathe is a gaseous mixture (air), which is composed of 21% oxygen and approximately 79% of nitrogen in normal conditions. During the session O2Hb pressure inside the chamber is increased two to three times the equivalent of atmospheric pressure, so that breathing oxygen at 3 ATA, Oxygen pressure values \u200b\u200bat the level of pulmonary alveoli amounted to 2.173 mmHg, the partial pressure of arterial oxygen (PaO2) to 1.800 mmHg rise in venous blood levels reaches 200 to 300 mm Hg, hemoglobin is saturated at 100% ability, diffusion distance is increased 8 times and while in normal plasma 0.3 vol/100 carries with O2Hb vol/100 rises to 6.6 (20 times).
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HISTORICAL
Although scientific-based applications cally in hyperbaric technology are newly developed, the use of compressed air has ancient roots as described Hensaw British physician (1662), long before the oxygen was identified as an individual. The doctor realized that the large increase in air pressure could ease some serious injuries. He built a camera which he called "home", whose function was the administration of air at different pressures for him treating various chronic diseases.
Use of Oxygen for medical problems initially reported by Beddoes (1794). The first article of the use of oxygen under pressure (hyperbaric oxygen) as adjunctive therapy was described by the French surgeon Fontaine in 1879. In Latin The first hyperbaric chamber was built in Canada in 1860, a year later in New York, for treatment of nervous disorders. In 1939, Albert Behnke reported the first clinical use O2Hb to treat decompression sickness. In the decades around the years 1950-60 they began to lay the physiological bases O2Hb, demonstrating that it is capable of combat tir anaerobic bacteria infections and to improve tissue oxygenation in separately from the amount of hemoglobin. In 1960, Boerema, considered the father of modern Hyperbaric Medicine in its publication Life without Blood, tells the replacement of blood plasma in pigs, expanding pressure of oxygen air three times, all without apparent adverse effects observed, although hemoglobin levels of pigs was almost zero. In these same decades has accelerated the study of oxygen in the fields of aviation and marine diving, especially at NASA.
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SCIENTIFIC COMMUNITIES
Many countries have made scientific medical organizations dedicated to the investigation and treatment with hyperbaric oxygen. In 1967 he founded the Undersea and Hyperbaric Medical Society (UHMS) located in Maryland, which is responsible for the approval of medical conditions that respond to hyperbaric oxygen treatment. In 1976 he founded the Hyperbaric Oxygen Committed, an organization that is responsible for the ongoing review of new research and clinical applications, to issue recommendations on the subject of dealing with disorders O2Hb. Globally in 1988, created the regulatory agency International Society of Hyperbaric Medicine.
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O2Hb CONCEPT
Manage 100% pure oxygen under atmospheric pressure patients increased from 1.5 to 3 ATA in a hyperbaric chamber, carefully controlling the oxygen level and atmospheric pressure.
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PHYSIOLOGICAL EFFECTS.
The O2Hb combines two mechanisms: first, a high ambient pressure and the other, the respi-ration of 100% pure oxygen. This causes two effects: a volumetric effect and an effect solumétrico.
The volumetric effects due to increased environmental pressure and is based on Boyle's Law, which postulates that the human body, raising the ambient pressure is inversely proportional decreases in the volume all body cavities that are not in contact with the respiratory tract (bladder, digestive tract, ears, sinuses, etc.). This effect is reversible upon cessation of overpressure.
Solumétrico Effect is due to increased partial pressure of O2 and is based on Henry's Law which holds at the same temperature and increasing pressure, increases the dissolution of gas in a liquid, so that breathing 100% pure oxygen in a hyperbaric atmosphere, increases dissolved oxygen in the plasma after saturated hemoglobin.
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CELLULAR AND BIOCHEMICAL EFFECT
Oxygen is a chemical element with atomic number 8 and atomic weight 15.99, density is 1.105g/cm3. It has a diatomic molecule, but there is also the triatomic molecule. It is essential for the cells because the latter derive their energy for respiration, due to the ability of chemical bonds. Increased oxygen tension results in increased phagocytic activity of white blood cells, outlined as follows: polimorfonuclears leukocytes, neutrophils, eosinophils and mononuclear phagocytes represent the first and most important line of defense against microorganisms that are introduced into the body. Bacterial death usually has 2 phases: the 1 st. Degranu Phase-tion involves, in which the bacteria digested is exposed to various substances. The 2. Is the oxidative phase, which depends on molecular oxygen captured by the leukocyte. Under normal conditions, the phagocytic cell is at rest and a stimulus to produce the respiratory burst characterized by a dramatic increase in oxygen consumption, it generates highly toxic and arousal reduction of oxygen, oxygen-dependent microbicidal mechanisms (MMODE) , which is the set of changes to the metabolism of oxygen and takes place in phagocytes with a large number of soluble and particulate stimuli that alter their membranes, they are usually composed of inflammatory processes: opsonisados \u200b\u200bmicro-organisms, com-fragment of complement C5, oligopepetidos N-formylated bacterial, and leukotriene B4. Everything associated with increased glucose oxidation. It occurs as a result, highly toxic metabolites such as superoxide, hydrogen peroxide, hydroxyl radical and oxygen siguelete. The superoxide anion is formed by the univalent reduction of oxygen, ie the capture of an electron, by action of a membrane oxidase system of PMN, the NADPH oxidase. Superoxide anion undergoes spontaneously or by action of superoxide dismutase (SOD), a disproportionation reaction to form hydrogen peroxide, which for bond cleavage-OO-(peroxide) is highly oxidative oxygen species such as hydroxyl radical (O =). On the other hand myeloperoxidase catalyzes the reaction of hydrogen peroxide with chloride anion resulting in the anion hypochlorite, a powerful oxidant, from which lipophilic chloramines are generated highly toxic. All of these oxidants have high toxicity for different organisms that have low stress protection against oxygen. The absence or low concentrations of protective enzymes against oxidative effect (catalases, peroxidases) causes an increase in the partial pressure of oxygen in the environment surrounding this highly hostile environment for survival this type of bacteria.
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ANTI-EDEMA EFFECT
Inflammation is a general defensive response of all higher organisms, which has a protective nature and its purpose is to rid the body of the initial cause of tissue injury. After altering the tissue produces a disorder that explains their circulatory cardinal signs: Blush, Tumor, Calor, pain and impaired function. The key feature is the reaction of blood vessels (vasodilation), alterations of microvascular permeability (edema formation) and defense cell accumulation. In soft tissue trauma injuries occur that affect various tissues of a compartment or several compartments of an area or region. In all cases there is local hypoxia (PO2 drop mitochondrial critical level, 1 point or Pasteur mmHg) secondary to blood flow deficit due to injury or compression of vessels and reduced transport capacity. By using O2Hb, peripheral vasoconstriction occurs hyperbaric a physio-logical mechanism of defense against hyperoxia, and therefore only affects healthy tissues. When a local state of hypoxia (edema), this area benefits deprived plasma volume at the expense of healthy territories; ie, a phenomenon similar to known arterial steal in reverse, so that healthy tissue hypoxic tissue supercharging, Effect of Robin Hood. This effect is able to recover and overcome the pressure from 2 to 5 mm Hg, with which the EU-lula carried out a series of biochemical reactions important micas. In conclusion, the effects of trauma are O2Hb reverse tissue hypoxia, reduce swelling by vasoconstriction, by reducing blood flow (compensated by hyperoxia).
Oral Surgery extensive edema of mild to moderate O2Hb treatable. Maxillo-facial Surgery elective post-surgical benefits are explained by the mechanism O2Hb action. In severe facial injuries, the pre-surgical O2Hb may decrease the waiting time for reconstruction (usually wait until the swelling is resolved or controlled for surgery), shortening the time of hospitalization and ultimate recovery. In these patients, there is usually traumatic brain injury with varying degrees of cerebral edema (cytotoxic or vasogenic) appreciably improves the O2Hb. In face of traumatic events with accidental or surgical wounds may be blocking lymphatic return that prevents absorption of fluids and proteins that normally traffic exchange capillary (extracellular edema, increased fluid in the interstitial space).
Normally, lymph vessels of the forehead and the anterior region of the face accompanying facial and other vessels drain into the submandibular lymph nodes. The lymphatics of the lateral region of the face, including eyelids, drain inferiorly into the superficial parotid lymph nodes. At the same time they drain into the deep parotid lymph, which is to drain into the cervical linfonóudlos. The nodes of the upper lip and the side portions of the lower lip drains into the submandibular lymph nodes tubular, while the nodes in the central part of the lower lip and chin drain into the lifnonódulos submentoneanos, from which the lymph drains directly into the jugular lymph nodes omonioideos.
erythrocyte saturation with 100% oxygen in the pulmonary alveoli
Home of the respiratory chain in the leukocyte
traumagenic edema should be differentiated from other conditions in the region that bucomaxilofacial can also occur where the use of O2Hb may be considered and decided by the expert. There is increased capillary permeability in infections with extracellular edema, ischemia, burns, exposure to toxins, vitamin deficiency and immune response in lymph blockages CA, infections and surgery on lymphedema is swelling of part of the region face due to the accumulation of lymph in the tissues, mainly in the fat beneath the skin, as a result of problems in the lymphatic Sitema characterized by excessive accumulation of protein in tissue fluid (edema), chronic inflammation, thickening and scarring connective tissue; in Melkerson-Rosenthal syndrome consisting of recurrent swelling of the lips, intermittent facial paralysis and scrotal tongue.
clinical edema can also be the result of intracellular edema. The main causes are: decrease in cell metabolism and loss of proper cellular nutrition. This edema occurs in states of shock and others with compromised cardiac output. Decreased oxygen and nutritional supply in the cell results in depression of the cell's metabolic ability to pump out excess Na, this accumulation of intracellular Na H2O attracts inward.
intracellular edema in Inflammation usually occurs as a result of increased permeability induced by the inflammatory process. Typically, the highest concentration of oxygen and nutrients in the capillary plasma promotes the dissemination of these to the tissues where they are constantly consumed. In contrast, the high concentration of CO2 and waste products in tissues, promote the diffusion of it into the blood plasma in the veins. Therefore, the high availability of oxygen in the microcirculation, obtained with the O2Hb promotes repair of damaged tissue.
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IN CHRONIC REFRACTORY OSTEOMYELITIS
Some chronic osteomyelitis in the form evolutionary refractory are rebels all forms of treatment, so the disease continues for an indefinite period. Is sometimes little vascularized laminar cortical bone, as in some sectors of the mandible. It can occur as a result of laborious and traumatic extractions, associated with intraosseous pus that is watered by the cancellous bone (trabecular) limited by the cortical. This torpid evolution is due to the adoption of mechanisms of resistance by the respon-sible microroganismo and the ineffectiveness of the natural mechanisms of defense against an inaccessible area, hypoxic and poor or no bioavailability of antibiotics. One of the most important problems is the existence of a barrier-tion between infection and the host intact, which may consist of necrotic bone, oozing, avascular scars, etc. The clinical picture can present with spontaneous purulent vestibular groove, with a diagnostic nuclear medicine box, characterized by an uptake in the study area in three phases. Histological analysis may show chronic inflammatory infiltrate with necrotic bone trabeculae. O2Hb stimulates the permeability of this barrier, promotes fibroblast division and hydroxylation of precolágeno, increasing production of collagen (with increased PO2 between 20 and 30 mmHg), creating the structural basis for angiogenesis, in addition to surgical debridement microscopic osteoclast function produced by the infected or necrotic bone. After 20 sessions O2Hb-tions, histological studies revealed revascularization and formation of healthy bone. In short we can describe the O2Hb acts favorably on the refractory osteomyelitis in the facial area by increasing osteoclast function and osteo-genesis, vascular neoformation, the phagocytic activity of leukocytes, the elimina-tion Direct aerobic and anaerobic bacteria bias, the potentiation effect of aminoglycosides, the mechanisms of host defense, favors processes trización scarring by increasing collagen, reducing local edema and diffusion barrier.
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EFFECT ON OSTEO-radionecrosis
Ionizing radiation affects tumor tissue and healthy tissue. On the soft tissue causes atrophy of the skin, ulcers, on the blood vessel inflammation, degeneration and necrosis of the endothelium, thickening of the endothelium, proliferative vasculitis and necrotizing arteritis. A bone level is no effect on the glass san-guinea and death of bone necrosis. As described in the above concepts, the O2Hb has beneficial effects and proper recovery by raising the PO2 at the cellular level, triggering the cascade of angiogenesis hyperoxia increases the activity of osteoclasts on bone tissue and necrotic osteogenesis.
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EFFECT ON GRAFT
After excision of the graft, blood vessels collapse. The minimum pressure should be 1-2 mm of blood per minute per 100 grams of tissue, whether this low pressure that produces a big amount of free radicals, hypoxia, necrosis and coma sequential myocytes, adipocytes and cells endothelial cells. Moreover, the grafted tissue where it is swollen and it brings destruction of the Na-K, free radicals and increased edema. Contraction of the microcirculation and hypoxia. The benefit is demonstrated by the O2Hb relieving hypoxia, tissue ischemia, promotes microcirculation, decreases platelet aggregation and metabolic disturbances of tissue hypoxia, raising the levels of phosphodiesterase and CPK.
In summary, the effects of O2Hb described above are:
1. Correction of hypoxic tissue states.
2. Stimulation of biosynthetic and reparative processes by stimulating the capillary angiogenesis, proliferation of fibroblasts and collagen synthesis.
3. Osteogenesis modulator process.
4. Potentiates the action of aminoglycosides.
5. Direct bactericidal and bacteriostatic anaerobic bacteria on aerobic.
6. Halts production of alpha toxin by anaerobic bacteria.
7. Synergistic action breaks own infections mixed bacterial flora.
8. Restores the phagocytic capacity of PMN.
9. Hypoxemic vasoconstriction is not favoring the reduction of interstitial edema and extravasation of plasma.
10. Limits the lifetime of COHb.
11. Antiplatelet and anteiserotonínico.
12. Porterior attenuates reperfusion injury to ischemic events.
13. Regulates the function gastroinstetinal promoting peristalsis, decreasing the mechanical effect of the gases, increasing the production of mucus and promoting intestinal absorption.
14. Promotes the synthesis of prostaglandins, steroid hormones and interferon production.
15. Modulator of the immune response.
16. Adjust the sensitivity of the hormone estrogen receptors and mediators.
17. Reducing the effect of mechanical and embolized gas diffusion.
18. Inhibition of leukocyte adhesion to vascular endothelium by modulating the inflammatory response.
19. Correcting tissue hypoxia associated with endoarteritis.
20. Marginal tissue preserved demarcating viable and nonviable.
21. Increases erythrocyte flexibility by encouraging the passage of blood in the microcirculation.
the O2Hb In dentistry can be applied directly to:
1. Traumagenic moderate and severe edema before and after reconstructive surgery or repair, combined with traumatic brain injury.
2. Odontogenic infection with abscess moderate and severe.
3. Post-surgical edema and extensive oral surgery.
4. Post-surgical edema in orthognathic surgery.
5. Osteomyelitis.
6. Osteo-radionecrosis.
7. Extensive grafts: bone and gingival mucous.
8. Tumor resection leaving bloody areas.
9. All acute inflammatory processes by their cost-benefit analysis to justify their use.
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19. Silver IA. Cellular Microenvironment in healing and non-healing wounds. In(Hunt TK Heppenstall RB, Pines E. Roree D. Eds) Soft and Hard Tissue Repair. Biological and Clinical aspects. New York: Praezer Scientific; 1984: 50-66.
