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Dr. ULLAS SAXENAJR IIORAL MEDICINE AND RADIOLOGYDENTAL MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

INTRODUCTIONThe key to successful dental management of medically compromised patient is accomplished by detailed history including past health condition, drugs and medications taken by the patients.All this information is should be applied to access the risk of problems related to specific conditions identified in the evaluation.Certain conditions have direct bearing on management and treatment of these patients which may have to altered or modified as a result.

SCREENING MEDICALLY COMPROMISED PATIENTS:GOAL: To evaluate any source of infection that may compromise successful medical or surgical therapy and restore optimal oral health and function.1. Full mouth intra-oral radiographs plus panoramic radiograph 2. Panoramic radiograph only if edentulous or not able to take intraoral films3. Thorough medical and dental history, including medications documented on the dental chart.4. Physician consultation to corroborate medical history and coordinate dental and medical care.5. Initiate preventive therapy.6. Arrange treatment.7. Arrange follow-up.

ANTIBIOTIC PREMEDICATION INDICATIONS1. Prosthetic heart valves2. Heart murmurs and history of Renal failure, Rheumatic heart disease.3. With congenital heart disease.4. Dialysis patients 5. Organ transplant patients and immunosuppressive patients.6. Chemotherapy patients, including bone marrow transplant7. Poorly controlled diabetic patients.8. Radiation therapy patients, depending on procedures.

Preoperative Management:

1. Good detailed medical history of the patient should be taken and updated during each visit. 2. The medical condition should be mentioned in the consent form. 3. Any problem in previous dental treatment should be reported precisely. 4. Report any previous hospitalization of the patient and the reason for it. 5. Early morning appointments are preferred except in cardiac patients which are preferred to be in late morning.

HYPERTENSION

Hypertension refers to blood pressure that is consistently above 140 /90 mm Hg ( for more than 6 months).The blood pressure must be controlled before any dental treatment or opinion of a physician must be sought first.It is essential to avoid stress and anxiety since endogenous epinephrine released in response to pain and fear may induce dysrhythmias.Patients are treated best late in the morning because epinephrine levels peak during morning hours and adverse cardiac events are more likely to occur in the early morning.

Patient with severe uncontrolled Hypertension could result in angina, stroke or Myocardial infraction.Stress and anxiety: may cause increase in blood pressure leading to angina, MI or stroke. In Patients using non-selective beta blockers, excessive use of vasoconstrictor can cause elevated BP (propanolol, pindolol,timolol etc.)Continuous BP monitoring is indicated.The management of hypertension is complicated by renal failure or any cardiac disease.Refer to patients physician for further advice.

Low blood pressure occurs on standing up (orthostatic, or postural, hypotension). This is a sudden drop in blood pressure when a person stands up from a sitting position or if he stand up after lying down. Ordinarily, gravity causes blood to pool in legs whenever a person stands.Raising the patient suddenly from supine position may cause postural hypertension and unconsciousness if he is using any antihypertensive drug.

Systemic corticosteroids may raise BP , must be adjusted accordingly.Some NSAIDS like indomethacin, ibuprofen, naproxen can reduce efficiency of antihypertensive drugs.While giving local anesthetic solution, epinephrine must be avoided or an aspirating syringe is used ( can elevate the BP causing shock and arrhythmias.)Adrenaline is contraindicated in patient with systolic BP more than 150 mm Hg and diastolic BP more than 110 mm Hg.Conscious sedation is advisable to control anxiety.Intravenous barbiturates can be dangerous if the patient is on antihypertensive therapy.Halothane, enflurane and isoflurane may cause hypotension in these patients.

DIABETIES MELLITUS

DM is a complex syndrome characterized by abnormalities in carbohydrate, lipid and protein metabolism that result either from profound or an absolute deficiency of insulin, related to autoimmune destruction of the insulin producing pancreatic beta cells(Type 1), or from target-tissue resistance to its cellular metabolic effects, related commonly to obesity(Type2)A carefully constructed questionnaire can give some indications that a patient could be at risk of being diabetic especially type 2.The classical symptoms of DM include : polydipsia, polyuria and polyphagia.

The following findings are also indicative of possible diabetes: recent weight loss, irritability, dry mouth, frequent infections, history of poor wound healing.It is recommended that a patient suspected by the dentist to be diabetic, should be referred to a physician for proper evaluation and diagnosis.Properly controlled type 1 and type 2 diabetic patients usually can undergo all dental treatments without special precautions.The dentist must know the type and dose of insulin as well as any other medications that the patient is taking.The most severe complication of diabetes mellitus is hypoglycemia i.e. Blood sugar level less than 70 mg /dl.The hypoglycemia has more dramatic results than hyperglycemia.Factors like diet, underlying systemic disease , hormones, steroids elevate blood sugar levels.

MANAGEMENT OF HYPOGLYCEMIA IN DENTAL OFFICE STOP THE PROCEDURE IMMEDIATELY.Essentially, a quick-acting carbohydrate needs to be given, followed by a longer-acting carbohydrate.Initially Glucose 10-20 g is given by mouth, either in liquid form or as granulated sugar (two teaspoons) or sugar lumps.Repeat capillary blood glucose after 10-15 minutes; if the patient is still hypoglycemic then the above can be repeated (probably up to 1-3 times).Glucose, fruit juices must be available in dental office for diabetic patients.

If hypoglycemia causes unconsciousness, or the patient is unco-operative:Intravenous administration of 75-80 ml 20% glucose or 150-160 ml of 10% glucose (the volume will be determined by the clinical scenario).25 ml of 50% glucose concentration is viscous, making it more irritant and more difficult to administer intravenously. It is rarely used now.Once the patient regains consciousness, oral glucose should be administered, as above.Check the blood sugar with glucometer.

Do not continue the procedure after patient becomes normal.call the patient next day.Glucose drinks must be available in dental office for diabetic patients.Local anesthesia without Adr is given because Adr may elevate blood glucose levels .Complicated dental procedures must be avoided.If hypoglycemia is not managed , it can lead to diabetic coma.

DYSRHYTHMIA

Dysrhythmia refers to abnormality in rate , sequence of cardiac activation due to disturbance in cardiac impulse generation or conduction.It is commonly seen in patients with ischaemic heart disease or myocardial infraction.Management :Limit the epinephrine level to 0.04 mg.Stop dental treatment.If angina pectoris occurs, administer oxygen ,minimize stress and wait till pain resolves.

BRONCHIAL ASTHMA

Bronchial asthma is a generalized airway obstruction which in the early stages is paroxysmal and reversible.The obstruction, leading to wheezing, is due to bronchial muscle contraction, mucosa swelling and increased mucus production.Exposure to allergens and/or stress can induce an attack. It is now accepted fact that inflammation is an important etiological factor in asthma and this has resulted in the use of anti-inflammatory medication in the management of the condition.

TRIGGERS OF BRONCHIAL ASTHMA

Infections of the upper airways, for example, colds and flu.Allergens such as dust mites, pollens, animal fur molds or feathers.Airborne irritants such as including fumes, pollution and cigarette smoke.Certain medicines like painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs).Emotions Laugher or stressFood additives like sulfites and tartrazine.Weather conditions : sudden changes in temperature, exposure to cold air, thunderstorms and humid hot or days.Indoor conditions like mold, carpet cleaning chemicals and flooring materials.ExerciseGastroesophageal reflux disease (GERD)Food allergiessmokingAlcohol

MANAGEMENT OF ASTHMATIC ATTACKAlthough there is no cure for Asthma, the proper treatment will make an enormous difference in preventing long-term as well as short-term complications caused by Asthma. If asthmatic attack occurs in dental chair, stop the procedure.Administer antiasthamatic drug normally used by the patient followed immediately by hydrocortisone 200 mg intravenously along with oxygen. If there is no response within 2 to 3 minutes, give salbutamol or terbutaline by slow intravenous injection or 1 ml in 1000 Adr intramuscularly.A proper case history must be taken of an asthmatic patient and all dental counsel must take precaution to do safe procedures and must avoid treatments which may trigger an attack.

Avoid anxiety which may precipitate an asthmatic attack.Patients are advised to bring their regular medication with them.Elective dental care should be deferred in severe asthmatics until they are in a better phase.Patient should not be treated during sickness e.g. flu-like symptoms.Allergy to penicillin may be more frequent.Epinephrine, erythromycin, clindamycin and azithromycin are contraindicated for patients on theophylline.

Infrequent attacks of asthma can be managed by salbutamol (asthalin) inhalers or can be used prophylactically if an attack is predicted. e.g. before exercise or prior to a stressful event such as dental treatment.If the attacks are more frequent, the salbutamol should be used regularly.If this is insufficient, inhaled steroids (or cromoglycate in the young patients)should be used.In severe cases systemic steroids may be prescribed.

Avoid the use of Local anesthetics containing vasoconstrictor due to reaction with sulphites present as preservatives in it.Aspirin and NSAIDs should be avoided as they are considered asthma precipitating drugs.Patients on steroid inhalers are prone to oral and pharyngeal thrush and those on ipratropium bromide may have dry mouth.Avoid antihistamines such as promethazine and diphenhydramine because of their drying effect that can exacerbate the formation of tenacious mucus in acute attack.

ANGINA PECTORIS

Angina is a symptom of ischemic heart disease produced when myocardial blood supply cannot be increased to meet the increased oxygen requirement as a result of coronary heart disease.Dental aspects:Preoperative glyceryl trinitrate and oral sedation must be e.g. Tremazepam are advised .Effective local anesthesia is essential.Ready access to medical help, oxygen and nitroglycerine are essential.

MYOCARDIAL INFARCTION( HEART ATTACK )

MI is a condition caused by necrosis of a region of myocardium due to decrease in myocardial supply.It is characterized clinically by substernal pain which stimulates angina pectoris but is of more intense and is of longer duration.Signs and symptoms:DyspneaOrthoponeaGiddinessNauseaVomitingLight headedness

MANAGEMENT OF MYOCARDIAL INFARACTION PATIENT WITH RECENT ATTACK OF MI ( WITHIN 6 MONTHS ):These patients are on anticoagulants and are on increased risk of another episode.Delay of dental treatment for 6 months is advisable.PATIENTS WITH EPISODE OF MI( LESS THAN 6 MONTHS ):Anxiety reduction protocol must be followed.Dental treatment must be carried out with effective Local anesthesia, less anxiety and oxygen saturation.Gingival retraction cords having Adr must be avoided.

AN EPISODE OF MI ON DENTAL CHAIR :Terminate all dental treatment if he complaints of chest pain.Remove all foreign objects including cotton gaugeChange the patients position to patients comfort. ( mostly upright) .Administer 0.5 mg Glyceryl trinitrate ( GTN) sublingually.Monitor vials.Postpone dental treatment if can be done.Position the patient in a semi reclined procedure if he is unconscious.If conscious, change position to sitting procedure.Repeat this after 5 minutes.

HEPATITIS B INFECTION

Hepatitis B is an infectious disease caused by the hepatitis B virus (a DNA virus ) which affects the liver. If not treated, can cause liver cancer.It can cause both acute and chronic infections. Many people have no symptoms during the initial infection. Some develop a rapid onset of sickness with vomiting, yellowish skin, tiredness, dark urine and abdominal pain.

The main problems are: highly infective disease, bleeding tendency and drug sensitivity.Pure saliva does not contain HBsAg, but serum via gingival exudates does.Blood, plasma or serum can be infectious as little as 0.0000001 ml of HBs Ag.Dentist should treat the patient within the current regulations for cross infection control.Patients with active acute hepatitis B should have dental treatment after complete recovery only, which take about three months after symptomatic recovery.

Needle stick injury can transmit the virus. An injection of hepatitis B immuno- globulin (HBIG) within 24h of contact may protect from developing hepatitis.Hepatitis carriers may have chronic active hepatitis, leading to compromised liver function and interfering with hemostasis and drug metabolism. Physician consultation or laboratory screening for liver function is advised.Any patient having signs or symptoms suggesting hepatitis should be referred to a physician, and should not be treated. If emergency care becomes necessary, it should be provided as for the patient with acute disease.

HEPATITIS VACCINE DOSESDose AdjustmentsAlternate dosing schedules (Engerix-B(R)):11 to 19 years: 3 doses (20 mcg each), IM, on a 0, 1, and 6 month schedule11 to 19 years: 4 doses (20 mcg each), IM, on a 0, 1, 2, and 12 month schedule20 years and older: 4 doses (20 mcg each), IM, on a 0, 1, 2, and 12 month scheduleBooster Vaccinations (when appropriate):Engerix-B(R):11 years and older: booster dose is 20 mcg

Oral complications associated with hepatitis:The only oral complication associated with hepatitis is the potential for abnormal bleeding in cases of significant liver damage.If surgery is required, it is advisable to:Check the prothrombin time. If it is greater than 35, an injection of vitamin K will usually correct the problem. This should be discussed with the patients physician.Monitor the bleeding time to check platelet function. If it is not less than 20 minutes, the patient may require platelet replacement before surgery.This should also be discussed with the patients physician.

LIVER DISORDERS

Patients have potential bleeding tendency, intolerance to drugs (e.g. general anesthetics, benzodiazepines) and the possibility of underlying infective causes for the liver dysfunction.Signs of liver disease :jaundice, spider naevi, leuconychia, finger clubbing, palmar erythema, dupuytrens contracture, sialosis and gynaecomastia.Patients with parenchymal liver disease have impaired hemostasis and can present serious bleeding problems.Disorders associated with an early rise in serum levels of conjugated bilirubin can cause dental hypoplasia and greenish discoloration of the teeth.Local anesthesia is safe given in normal doses, but prilocaine or articaine are preferred to lidocaine.

Severe bleeding can occur after dental extractions in patients with chronic liver disease and hence the clotting status must be tested. The commonest liver function test (LFT) involves the measurement of aspartate transaminase (AST) and alanine transaminase (ALT). ALT may also be raised in cardiac or skeletal muscle damage and is therefore not specific for liver disease.The use of any drug in a patient with severe liver disease should be discussed with the patients physician. Hepatic impairment will lead to failure of metabolism of many drugs that can result in toxicity.

LIVER FUNCTION TEST- NORMAL VALUES

In some cases dose reduction is required; other drugs should be avoided completely. The anti-fungal drug miconazole is contra-indicated if there is hepatic impairment and fluconazole requires dose reduction.Erythromycin, metronidazole and tetracyclines should be avoided.Antimicrobials such as pencillins, cephalexin and cefazolin can be safely given in normal doses.Acetaminophen can be used for analgesia in lower than normal doses.Aspirin and NSAIDs should be avoided because of the risk of gastric hemorrhage.

RENAL DISORDERS

Renal disease mainly comprises the so-called nephritic syndromes which may progress to chronic renal failure (CRF).Progression to CRF leads to the need for dialysis and possibly transplantation.CRF patients may be taking corticosteroid and other immunosuppression drugs. This can make medical management difficult for these patients.Potential problems include: Impaired drug excretion.Anemia.Bleeding tendencies.Associated anticoagulant therapy.Hypertension. Infections e.g. hepatitis BRenal osteodystrophy.

The main concern :bleeding tendency. Ensure careful hemostasis if surgery is necessary.Local anesthesia is safe unless there is severe bleeding tendency.Prophylactic antibiotics are to be prescribed due to immunosuppression.Dental treatment is best carried out on the day after dialysis.Tetracycline should be avoided in chronic renal failure.Patients with renal failure are on immunosuppressive drugs.Drugs provided during dental treatment must be given with caution as some drugs may affect Glomerular filtration rate.

Aspirin and NSAIDs should be avoided as they affect renal function.Codeine and dihydrocodeine are favored as analgesics and diazepam may be used.Retarded teeth eruption can be demonstrated in children with renal failure.Dry mouth and decreased salivary flow result in calculus accumulation.Alter the dosage of drugs eliminated by kidney i.e. penicillin.

EPILEPSY

Epilepsy is a term that describes a group of disorders characterized by chronic, recurrent, paroxysmal changes in neurologic function (seizures) that are caused by abnormal electrical activity in the brain. Seizures may either be accompanied by motor manifestations or manifested by sensory, cognitive or emotional changes in neurologic function.

CAUSES OF SEIZURES IN DENTAL OFFICE:Hypoxia secondary to syncopeHypoglycemiaLocal anesthetic overdoseMissing of antiepileptic drug before treatmentHead injuryTRIGGERING FACTORS WHICH MAY PRECIPITATE EPILEPSY SYMPTOMS IN DENTAL OFFICE:Flashing lightsEmotional or physical stressMissed mealEpileptogenic drugsWithdrawal of anticonvulsant medication

The first step in the management is identification, which is best accomplished by the medical history(Seizure history: Type, age at onset, cause and medications).Make sure patient has taken his medication.Schedule patient early morning.Epileptics can have good and bad phases and dental treatment should be carried out in a good phase, when attacks are infrequent.Poorly controlled patients may require additional anticonvulsant or sedative medications, for these patients a consultation with the physician is advised before dental treatment.

Mouth prop is to be used during dental treatment.Keep equipments as much as possible away from the area of the patient.Be alert for any feature that may indicate the start of seizure.Aspirin and NSAIDs should not be administered to patients taking valporic acid (medicine used in treatment of epilepsy).Propoxyphene (analgesic drug) and erythromycin should not be administered to patients taking carbamazepine.

Oral Complications: the most significant oral complication is gingival overgrowth associated with phenytoin. The anterior labial surfaces of the maxillary and mandibular gingivae are most commonly and severely affected.Further, phenytoin is a teratogenic drug so must not given in pregnant women.

ADRENAL INSUFFICIENCY

Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones, primarily cortisol; but may also include impaired production of aldosterone (a mineralocorticoid), which regulates sodium conservation, potassium secretion, and water retention.A rare encountered factor which may result in unconsciousness is adrenal crisis.Adrenal insufficiency can also occur when the hypothalamus or the pituitary gland does not make adequate amounts of the hormones that assist in regulating adrenal function.This is called secondary or tertiary adrenal insufficiency and is caused by lack of production of ACTH in the pituitary or lack of Corticotropin-releasing hormone (CRH) , secreted by the paraventricular nucleus (PVN) of the hypothalamus in response to stress.in the hypothalamus, respectively.

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PREVENTION OF ACUTE ADRENAL INSUFFICIENCY:Based on history and questionnaire, acute adrenal insufficiency can be prevented.Adrenocortical suppression is considered if patient has had glucocorticoid therapy:In a dose of 20 mg or more of cortisoneVia oral or parenteral route for continuous 2 weeks or laterWithin 2 weeks of dental therapy.

CLINICAL MANIFESTATIONS:NauseaFatigueVomitingPain in abdomen, back , legsHypotensionMental confusionDENTAL CONSIDERATIONS:Stress reduction protocol must be followed.Avoid NSAIDS as they may precipitate peptic ulceration.Minor operations under local anesthesia must be done.Susceptibility to infection is increased by systemic steroid use.

MANAGEMENT OF ADRENAL INSUFFECIENCYTerminate all dental procedures.Monitor all vital signs.Administer glucocorticoid 200 mg hydrocortisone intravenously.Provide basic life support.Check blood pressure and sugar level.Repeat 200 mg hydrocortisone 200 mg at 4 -6 hours interval.

INFECTIVE ENDOCARDITIS

Infective endocarditis is infection of heart chambers and heart valves caused by bacteria, viruses or fungi.Infective endocarditis is usually caused by STREPTOCOCCUS VIRIDANS.Other causative organisms include Staphylococcus and Enterococcus.AGGREVATING FACTORS:Congenital heart diseaseRheumatic heart diseaseProsthetic heart valveScar tissue in cardiovascular system

DENTAL ASPECTS:For dental point of view , it is obligatory to prevent onset of infective endocarditis.This can be done by planned dental care.Proper sterilization of dental instruments and surroundings.Giving appropriate antibiotics at appropriate time.Proper case history and examination is must in managing patient with infective endocarditis.

ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS:

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Symptoms:Chronic bronchitis and emphysema both cause chronic cough and shortness of breath. Unique symptoms of chronic bronchitis are increased mucus and frequent clearing of the throat, while limited exercise tolerance is a common symptom of emphysema. The diagnosis of COPD is based on the results of lung function tests, the patients history, a physical examination and other tests.PRECAUTIONS PRIOR TO DENTAL TEATMENT:Postpone treatment till lung function has improved.Avoid sedation, hypnotics or narcotics.Seat patient in upright position in dental chair.Use stress reduction protocol.

COPD is a progressive pulmonary disease caused by excessive smoking.Chronic Obstructive Pulmonary Disease (COPD) is a term that refers to two lung diseases, chronic bronchitis and emphysema.The term COPD is used because both diseases are characterized by obstruction to airflow that interferes with normal breathing and the two frequently co-exist.In COPD, there is loss of elastic properties of airway, mucosal oedema, excessive secretion and bronchospasm.

Do not supply oxygen to the patient without consulting patients physician.In COPD , patient breathes with high Ci2 level and low O2 level.When , suddenly arterial O2 is increased, the hypoxia based respiratory stimulation jeopardized and rate of respiration becomes very low.DENTAL ASPECTS:Patients with COPD are treated in upright position as they are orthopneic.Interaction of drug such as theophylline with epinephrine, erythromycin, clindamycin, ciprofloxacin may result in high levels of theophylline.

Relatively , analgesia is given if only necessary.Intravenous barbiturates are contraindicated.General anesthesia must be given only if needed.Patients must be treated in dust fee and aerosol free atmosphere.Drugs such as bronchodilators must be available in dental office for managing COPD patients.Consult patients physician for assistance.

BLEEDING DISORDERS

A bleeding disorder is a condition that affects the way the blood normally clots. The clotting process, also known as coagulation, changes blood from a liquid to a solid. When you're injured, the blood normally begins to clot to prevent a massive loss of blood. Patients with bleeding disorders need special attention prior to any dental treatment.A proper clinical examination and case history is must for patients with bleeding disorders.CLINICAL FEATURES:Easy bruising.Bleeding gums.Heavy bleeding from small cuts or dental work.Unexplained nosebleeds.Heavy menstrual bleeding.Bleeding into joints.Excessive bleeding following surgery.

For the purpose of history-taking, a clinically significant bleeding episode is one that: continues beyond 12 hours causes the patient to call or return to the dental practitioner or to seek medical treatment or emergency careBleeding results in the development of hematoma or ecchymosis within the soft tissues or requires blood product support.Most reported bleeding episodes are minor and do not require a visit to the dentist or the emergency department and do not affect dental treatment significantly.

The management of patients with bleeding disorders depends on the severity of the condition and the invasiveness of the planned dental procedure. If the procedure has limited invasiveness and the patient has a mild bleeding disorder, only slight or no modification will be required.In patients with severe bleeding disorders, the goal is to minimize the challenge to the patient by restoring the hemostatic system to acceptable levels and maintaining hemostasis by local and adjunctive methods. The patients physician should be consulted before invasive treatment is undertaken. In patients with drug-induced coagulopathies, drugs may be stopped or the doses modified. For irreversible coagulopathies, replacement of missing factors may be necessaryMANAGEMENT OF PATIENTS WITH BLEEDING DISORDERS

CONCLUSIONA proper case history and thorough clinical examination must be done during dental treatment of medically compromised patients.Every dental procedure or medication can alter medical status of medically compromised individual.Management of these patients must be done carefully and these patients must be provided special care with proper planning .

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