Good Morning

3/28/2015

3:23 PM

DENTAL MANAGEMENT OF THE

MEDICALLY COMPROMISED PATIENT

PRESENTED BY:

Keshav Mehta

BDS 4th Year3/28/2015

3:23 PM

Systemic diseases include:

1. Cardiovascular diseases

2. Respiratory diseases

3. Liver diseases

4. Endocrine diseases

5. Renal diseases

6. Neurogenic diseases

7. Blood diseases

9. Pregnancy & breast feeding 3/28/2015

3:23 PM

CARDIOVASCULAR DISODERS

3/28/2015

3:23 PM

Patient Evaluation/Risk Assessment

• Review medical history and engage in direct discussion of relevant issues

with the patient.

• Identify all medications and drugs being taken, or supposed to be taken,

by the patient.

• Examine the patient for signs and symptoms of disease, as well as obtaining

vital signs.

• Review/obtain recent laboratory test results or images.

• Obtain a medical consultation if the patient has a poorly controlled or

undiagnosed problem, or if the patient’s health status is uncertain.3/28/2015

3:23 PM

Main signs & symptoms of C.V.S diseases

1. Chest pain

2. Dysnea

3. cyanosis

4. palpitation

5. Syncope

6. Edema of ankles

7. Cold pale extremities

8. Clubbing fingers

9. Easy fatigue3/28/2015

3:23 PM

ISCHEMIC HEART DISEASES

Mode of presentation of ischemic heart disease:

1. Angina pectoris

2. Myocardial infarction

3. Acute coronary insufficiency

4. Cardiac arrhythmia

5. Heart failure

6. Sudden death ( cardiac arrest, ventricular fibrillation )

7. Asymptomatic ( silent3/28/2015

3:23 PM

Risk assessment for the dental management of patients with ischemic heart disease

involves three determinants:

1. Severity of the disease

2. Type and magnitude of the dental procedure

3. Stability and cardiopulmonary reserve of the patient

3/28/2015

3:23 PM

Dental Management Considerations for Patients with Stable (Mild)

Angina or Past History of Myocardial Infarction (MI), Without

Ischemic Symptoms

Analgesics: Ensure adequate postoperative pain control.

Anesthesia: Avoid use of excessive amounts of epinephrine; limit to two carpules of

1:100,000 epinephrine at a time (within 30-45 minutes); greater quantities may be

tolerated well clinically but with increasing risk.

. Anxiety: Use stress reduction protocol . Consider the use of preoperative oral sedation

1 hour before procedure, as well as using N2O-O2 inhalational sedation intraoperatively.

3/28/2015

3:23 PM

Bleeding:If patient is taking aspirin or other antiplatelet medication,

anticipate some excessive bleeding, but modification of drug regimen is not

required.

Chair position: Ensure a comfortable chair position and avoid rapid

position changes.

Drugs: The use of excessive amounts of epinephrine with nonselective beta

blockers can potentially cause a spike in blood pressure, but this is unlikely

and appears to be dose-dependent; avoid the use of epinephrine

impregnated retraction cord. 3/28/2015

3:23 PM

Equipment: Consider taking preoperative vital signs and the use of a pulse oximeter if

oral sedation is used, or if the patient becomes symptomatic.

Emergencies: Precipitation of an angina attack, MI, arrhythmia, or cardiac arrest is

possible. Have nitroglycerin readily available as well as oxygen. Be prepared to

perform CPR .

Follow-up: Ensure that patient is maintaining regular follow-up visits with physician

3/28/2015

3:23 PM

3/28/2015

3:23 PM

Heart Failure

It is the pathophysiological process in which the heart as a pump is unable to meet

the metabolic requirements of the tissue for oxygen and substrates despite the

venous return to heart is either normal or increased.

It is Clinical syndrome … can result from any structural or functional cardiac

disorder that impairs ability of ventricle to fill with or eject blood.

3/28/2015

3:23 PM

Dental Management Considerations in Patients with Heart Failure (HF)

Antibiotics: Patients with HF may be more susceptible to infection (leukopenia), but

usually this is not a problem. There is no need for antibiotic prophylaxis unless the

patient has a prosthetic heart valve or another cardiac condition.

Anesthesia: It is very important to achieve and maintain excellent anesthesia in

order to reduce stress and prevent cardiac crisis. Use of epinephrine (1 :100,000) at a

dose of no more than 2 carpules in local anesthetics generally causes no problems,

but patients should be monitored closely.

3/28/2015

3:23 PM

Anxiety Patients: with untreated or poorly controlled HF may appear very anxious and

stressed and are at risk for cardiac crisis. Use of special anxiety/stress reduction

techniques.

Chair position: Positioning usually is not a problem if the patient is under good medical

management;

however, a patient who is becoming hypotensive and syncopal from cardiac stress and

pulmonary congestion may not tolerate the supine position.

Consultation: Once the patient is under good medical management, the dental treatment

plan can

be implemented without changes. Initially, however, consultation with the patient’s

physician to establish the level of control is recommended as part of the management

program.

3/28/2015

3:23 PM

3/28/2015

3:23 PM

Devices: Dental patients with a diagnosis of HF may have pacemakers, implanted

defibrillators, or prosthetic valves, in which case published guidelines should be

followed.

Drugs: Patients with HF typically are on many medications. The dentist should be

aware of potential side effects and interactions. The use of epinephrine or other

pressor amines must be avoided. Digitalis toxicity may present a problem, so

prevention should be exercised in treating those patients.

HYPERTENSIVE DISEASES

Hypertension is considered to be the elevation of the blood pressure

greater than 140/90 mm of mercury

Uncontrolled hypertension can have the following surgical and anesthetic

complications:

1. It reflects on the cardiac status of the patient, thereby increasing the

anesthetic risk to the patient.

2. It causes excessive bleeding from the operation site, thereby

complicating the surgical procedure, as well as significant blood loss for

the patient 3/28/2015

3:23 PM

Preoperative Investigations

Chest radiograph—posteroanterior view for detecting

cardiac enlargement

ECG

USG of the kidneys

Ophthalmic evaluation for papilledema and retinal

hemorrhage

Renal function tests (blood urea nitrogen, serum creatinine and serum

electrolyte).3/28/2015

3:23 PM

Preoperative Medication and Management

The patient’s blood pressure should be monitored and controlled

within the normal permissible limits, prior to the surgical

procedure.

If the patient is on antihypertensives, the morning dose of

medication prior to surgery must be given with sips of water.

3/28/2015

3:23 PM

Intra and Postoperative Management

1. The blood pressure should be monitored continuously intra and

postoperatively.

2. The patient’s cardiac status should also be monitored on the ECG

machine and on the pulse oximeter.

3. Antihypertensives must be continued intra- and postoperatively.

4. If the patient is on diuretics, the patient must be supplemented

postoperatively with intravenous potassium supplements.

5. If the procedure is performed under local anesthesia, then local anesthetic

without adrenaline or bupivacaine, which does not have any significant

effect on the cardiac status is to be used.3/28/2015

3:23 PM

Prevention of problem Detection of patients with hypertension and referral to a physician if poorly controlled

or uncontrolled. Defer elective dental treatment if blood pressure (BP) is ≥180/110 mm

Hg.

• For patients who are being treated for hypertension, consider the following:

• Take measures to reduce stress and anxiety.

• Avoid the use of erythromycin or clarithromycin in patients taking a calcium channel

blocker.

• Avoid the long-term use of nonsteroidal antiinflammatory drugs (NSAIDs).

• Provide oral sedative premedication and/or inhalation sedation.

• Provide local anesthesia of excellent quality.

• For patients who are taking a nonselective beta blocker, limit epinephrine to ≤2

cartridges of 1 : 100,000 epinephrine.

• Avoid epinephrine-containing gingival retraction cord.

• For patients with upper-level stage 2 hypertension, consider intraoperative monitoring

of BP, and terminate appointment if BP reaches 180/110.

• Make slow changes in chair position to avoid orthostatic hypotension. 3/28/2015

3:23 PM

PROPHYLACTIC ANTIBIOTIC

REGIMEN FOR CARDIAC PT.

1. Under L.A

a) Adults---- 2gm Amoxicillin or 2gm Ampicillin

(1 hour before treatment orally) OR

(1/2 hour ,,, ,,,,,,,,,,, injection)

B) Children----- 50 mg per Kg Amoxicillin or

Ampicillin

3/28/2015

3:23 PM

IF PATIENT IS ALLERGIC:

Adult --------- Clindamycin 600 mg OR

Azathromycin 500 mg OR

Cephazolin 1 gm

(1 hour before tt. Orally)

( ½ ,,, ,,,, ,,, injection)

Child --------- Clindamycin 20 mg per Kg.

Azathromycin 15 mg per Kg.

3/28/2015

3:23 PM

2. Under G.A

a) Adults----- 1gm Amoxicillin I.V at induction.

OR 3gm Amoxicillin orally 4 hours before induction followed by

3gm Amoxicillin immediately after recovery.

OR 300mg Clindamycin I.M ½ hour before induction.

OR 300mg Clindamycin I/V at induction

b) Children ------ (5–10 years)1/2 adult

. (< 5 years) 1/4 adult

3/28/2015

3:23 PM

3/28/2015

3:23 PM

RESPIRATORY

DISORDERS

3/28/2015

3:23 PM

RESPIRATORY DISORDERS

Respiratory diseases can be categorized into obstructive and infiltrative

pulmonary diseases. Obstructive pulmonary diseases include, chronic

obstructive pulmonary conditions like asthma, chronic bronchitis,

pneumothorax and emphysema. Infiltrative diseases are inclusive of

diseases that cause inflammatory changes in the alveolar walls. Any

respiratory disease is first characterized by dyspnea.3/28/2015

3:23 PM

Common symptoms:

1. cough.

2. wheezing.

3. cyanosis.

4. finger clubbing

AVOID

1. General anesthesia: leads to hypoxia .

2. Analgesics & narcotics: leads to respiratory depressants.

3/28/2015

3:23 PM

BRONCHIAL ASTHMA

It is due to bronchospasm or hyperirritability of the

tracheo_bronchial tree.

Patient is treated by:

1. Corticosteroids inhalators.

2. Bronchodilator.

3. Beta adrenergic stimulator.

3/28/2015

3:23 PM

Preoperative Investigations

1. Chest radiograph—posteroanterior view

2. Pulmonary function tests

3. Blood investigations like arterial blood gases

4. Sputum AFB/Culture

5. Bronchoscopy, if required.

The patient should be counseled to discontinue beedi/cigarette smoking

prior to the procedure. Any acute infection should be treated by antibiotics.

The patient should be on bronchodilators pre, intra, and postoperatively.

The patient must carry inhaler for use in case of an emergency.3/28/2015

3:23 PM

Dental Management

Considerations in Patients with Asthma

Patient Evaluation/Risk Assessment

• Evaluate and identify asthma as a medically confirmed or likely diagnosis along with

its severity and type if present.

• Obtain medical consultation if asthma is poorly controlled (as indicated by wheezing or

coughing, or a recent hospitalization) or is undiagnosed, or if the diagnosis is uncertain.

Ecourage current smokers to stop smoking.

3/28/2015

3:23 PM

Antibiotics: Avoid erythromycin, macrolide antibiotics, and ciprofloxacin in patients

taking theophylline.

Anesthesia: The clinicians may elect to avoid solutions containing epinephrine or

levonordefrin because of sulfite preservative.

Anxiety: Provide stress-free environment through establishment of rapport and openness

to reduce risk of anxiety-induced asthma attack. If sedation is required, use of nitrous

oxide– oxygen inhalation sedation and/or small doses of oral diazepam is recommended.

3/28/2015

3:23 PM

Allergy: Asthmatics with nasal polyps are increased risk for allergy to aspirin.

Avoid aspirin use.

Blood pressure: Monitor blood pressure during asthma attack to observe for the

development of status asthmaticus

Chair position: Semisupine or upright chair position for treatment may be better

tolerated.

Devices: Instruct patient to bring current medication inhaler to every appointment;

use prophylactically in moderate to severe disease. Obtain spirometry reading to

determine level of control. Use pulse oximetry to monitor oxygen saturation during

dental procedure.

3/28/2015

3:23 PM

Drugs: Avoid precipitating odorants and drugs (aspirin). Avoid use of barbiturates

and narcotics, which can depress respiration and release histamine, respectively.

Supplemental steroids are unlikely to be needed in routine dental care; provide usual

morning corticosteroid dose the morning

of surgical procedures.

Equipment: Use low-flow (2 to 3 L/minute) supplemental O2 when oxygen

saturation drops below 95%; it also may become necessary when oxygen saturation

drops below 91%.

3/28/2015

3:23 PM

Emergencies: Recognize signs and symptoms of a severe or worsening asthma

attack: inability to finish sentences with one breath, ineffectiveness of

bronchodilators to relieve dyspnea, recent drop in FEV1 as determined by

spirometry, tachypnea with respiratory rate of 25 breaths/minute or

more, tachycardia with heart rate of 110 beats/ minute or paradoxical pulse.

Follow-up: Ensure that patient is receiving adequate medical follow-up care

on a routine basis.

3/28/2015

3:23 PM

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a general term for

pulmonary disorders characterized by chronic airflow limitation from the lungs

that is not fully reversible. COPD encompasses two main diseases: chronic

bronchitis and emphysema.

3/28/2015

3:23 PM

Patient Evaluation/Risk Assessment

• Evaluate and determine whether COPD is present.

• Obtain medical consultation if the condition is poorly controlled

(as manifested by dyspnea, coughing, or frequent upper respiratory infections)

or undiagnosed, or if the diagnosis is uncertain.

Review history and clinical findings for concurrent heart disease.

• Encourage current smokers to stop smoking.

Dental Management

Considerations in Patients with Chronic Obstructive Pulmonary Disease (COPD)

3/28/2015

3:23 PM

Antibiotics: Avoid erythromycin, macrolide antibiotics, and ciprofloxacin in patients

taking theophylline. In patient who has received courses of antibiotics for upper

respiratory infections, oral and lung flora may include antibioticresistant bacteria.

Anesthesia: Local anesthesia can be used without change in technique. Avoid

outpatient general anesthesia.

Anxiety: Avoid nitrous oxide–oxygen inhalation sedation in patients with severe

(stage 3 or worse) COPD. Consider low-dose oral diazepam or another

benzodiazepine, although these agents may cause oral dryness.

.3/28/2015

3:23 PM

Blood pressure: Patients with COPD can have cardiovascular comorbidity. Assess

blood pressure.

Chair position: Semisupine or upright chair position may be better for treatment in

these patients.

Devices : Avoid use of rubber dam in patients with severe disease. Use pulse

oximetry to monitor

oxygen saturation. Spirometry readings are helpful in determining level of control.

3/28/2015

3:23 PM

Drugs: Avoid use of barbiturates and narcotics, which can depress respiration.

Avoid use of antihistamines and anticholinergic drugs because they can further

dry mucosal secretions. Supplemental steroids are unlikely to be needed to

perform routine dental care; the usual morning corticosteroid dose should be

taken on the day of surgical procedures.

3/28/2015

3:23 PM

Equipment: Monitor oxygen saturation with pulse oximeter during sedation and

invasive procedures. Use low-flow (2 to 3 L/minute) supplemental O2 when oxygen

saturation drops below 95%; it may become necessary when oxygen saturation drops

below 91%.

Follow-up: At each follow-up appointment, encourage patient to quit smoking, and

examine oral

cavity for lesions that may be related to smoking. Avoid treatment if upper respiratory

infection is present.

3/28/2015

3:23 PM

References

3/28/2015

3:23 PM

3/28/2015

3:23 PM

HAVE A NICE DAY!!!