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High risk patients
Dr Bródy Andrea
Risk assessment
High risk patients
• Many patient with life-threatening diseases
now survive as a result of advances in surgical
and medical care
• Both could have affect the dental management
• 30% of dental patients have a relevant medical
Risk assessment
Risks related to general health condition
The general health condition of the patient
may be of risk:
• to himself (e.g. prosthetic valve, hemophilia)
• to the surroundings including healthcare
staff (e.g. infectious diseases)
• both (e.g. hemophilic HIV positive patients)
Risk assessment
No interventional procedure free from risk but
care can be improved by making an adequate
assessment based on:
history, clinical signs, investigations
minimizing trauma and stress
and choose the ideal time
relating with general
health status
Treatment is contraindicated in case of
• Acute infective diseases
• Patient in need of hospitalization
• Mental disorders in need of sedatives
• Anticoagulant therapy
• Severe allergic reaction to earlier dental
treament with unknown origin
Must find the solution!
Risk assessment
Pain in the legs and joints
Osteoporosis - Bisphosphonates
• Osteoporosis accounts for 1,5 millions new
• In people who sustain hip fractures less than
25% of them regain full function
• Bisphosphonates are analogues of inorganic
pyrophosphates and inhibit the resorption of
• Bisphosphonates are given orally in management of
osteoporosis, they are given IV to patients with
metastatic breast cancer, metastatic osteolytic bone
diseases and primary resorptive malignancies of
bone like multiple myeloma, Paget disease (act on
• Compared with other bones, the jaws have a higher
concentration of bisphosphonates – greater risk for
• Suspension of the bisphosphonate treatment
does not stop the progress
• Due to the long half life time, even after the
completion of the treatment the risk of BON
(bisphosphonate induced osteonecrosis of jaw)
is still present
• Prevention: Prior to starting the treatment all
dental problems must be eliminated, if possible
permanent tooth substitutions should be
• Warning signs: erithema, ulcer, movable teeth
• Patients with bone metastasis suffer jaw
necrosis in 2.8% of the occassions (Aredia,
Zometa, intravenal use) and 0,04% taking
• One of the main risk factors of the
development of necrosis is existing tooth or
periodontal disease, not properly fitting
removable denture, dental treatment
• It was caused in most cases by tooth extraction
and periodontitis
• Perioperative antibiotic
 There is no evidence of benefit in theire use
 If used, should be continued until oral mucosal
seal over the wound (5days), but no longer than
it is necessary
Chlorhexidin mouthwash
Rinsing with a CH solution before operation has
been shown to reduce the risk of alveolar osteitis,
and is recommended for prevention (0,12%twice
Rheumatoid arthritis
Immunosuppression (Biological therapy, steroids)
Decreasing the salivation - Sjögren syndrome
Candida infection, cheilitis angularis
Burning mouth syndrome
Patients with immune mediated
Organ transplant patients
Autoimmune diseases
Hemathologic malignancies
Biological and/or steroid therapy
Transplanted patients
• They often visit the dental office for focus
• Increased the susceptibility for infections –
immune supressed status
• Anticoagulant therapy
Dental management of
patients treated with anticoagulant
Recommendation of the Hungarian Association of
Oral and Maxillofacial Surgeons
• Complications are oftener after change the
small molecule heparin 0.8% (0,2 lethal)
risk of need hospital care postoperative bleeding in all groups 0,5% (non
It is refer for the following dental interventions:
Alveolar correction, implantation, extraction (radix
also), radix resection, probing of the parodontal issues,
incision of abscesses
PTE ÁOk, SE FOK 2015. 02.07
Dental management of
patients treated with anticoagulant
Not recommended:
1. Interrupt TAG (thrombocyta aggregation
inhibitors) treatment
2. Interrupt or switch VKA (K vitamin antagonists)
treatment if INR (potrombin time, international
normalized ratio) is ≤ 3,5
3. Interrupt NOAC (new oral anticoagulants)
PTE ÁOk, SE FOK 2015. 02.07
• Inform patient about the risk of bleeding
• In case of VKA controll the INR 24-72 earlier
• In case of NOAC the dental intervention must
happen just before swallow the pill (INR rate is
not adequate, no necessary to controll)
• No more than 3 teeth extraction in one time
• Treat on the start of the week and the workday
• Minimalize the trauma, in only one
• Primer closing – resorbable sutura, collagen
or celluloid spong
• Compression the surgical area 15-30 minutes and
rinse with 5% solution of tranexam acid (Exacyl) 1
day – 1 week
• Controll the patient 1 hour long after surgery
• Removing non-resorbable sutures after 4-7 days
• Replacing NSAID-s and ASA-s to paracetamol,
amidazophen or codein
• Inform patient about the possible complications and
the availability of medical service
Anticoagulant drugs
• Anticoagulant drugs
Heparins, small molecule heparins, cumarins
antidotum: protaminsulfat, K-vitamin
• Trombocyta aggregation inhibitors
E.g.: aspirin, clopidogrel
• New oral anticoagulants (rivaroxaban,
dabigatran) – INR (international normalized ratio) is not
Leukaemia, lymphoma, aplastic
• Leading to: anaemia, thrombocytopenia,
liability to infections, lymphadenopathia
• Septicaemia may spread from oral infections
• Preventive oral health care is essential
• Regional LA injections may be contraindicated –
in case of haemorrhagic tendency
Cardiovascular diseases
Cardial failure, MI
• General anaesthesia for dental care in cardiac patients
should be avoided
• Patients with stable heart disease receving treatment
under local anaesthesia – effective painless is essential
• Dental treatment in sitting position
• An aspirating syring should be used – avoid adrenalin get
into blood (high pressure, arrythm)
• Suddenly started dyspnoe, sweating, chest pain – break
the dental treatment, need emergency care
• Minimalize the stress and the pain
• Hypertension: essential to avoid pain – endogenous
adrenalin released in response to pain
Infectiv endocarditis (IE)
• Cardiac valves damaged by IE – at risk of
• Life-threatening infection – lethality is 1660%
• Streptococcus mutans and viridans enter the
bloodstream from dental plaque
• In 15% of the IE cases happened invasive
dental treatment within 1 month
Infectiv endocarditis
• Classification of patient based on IE risk in
• Low, simple and high risk group
No need of profilaxis in the low risk group
(coronaria bypass, after rheumatic fever
without valve defect, pacemaker)
• Prophylaxis is mandatory in the other two
groups (shunts, artificial valves, mitral prolaps,
history of IE, congenital heart defects)
Infectiv endocarditis
• In many countries there are guidelines for
antibiotic prophylaxis of IE, however the
efficacy has been questionable, and there is
always a risk of adverse reactions
• Death from antibiotics are possibly five to
six times more likely the death from IE
• UK National Institute for Health - completly
removing the need for antibiotic prohylaxis
in relation to dentistry
Profylaxis of IE
Desinfection of the oral cavity
• Local: rinsing 3 or 4 times per day with
clorhexidine or Solumium
• Antibiotic prophylaxis with single doses or
with a second in the most serious cases
Myocardial infarction (MI)
• After MI:
•Within 6 month of an MI are at greatest risk for further
MI – no dental treatment, only in emergency
•More than 6 month under 12 month – simple dental care
higher risk procedures as surgery leading 5-20% reinfarction
•More than 12 month patient can have normally elective
dental care
(Minimize pain and anxiety)
Patient should bring all the medication to dental office
Asthma bronchiale, COPD
• Patient should have
bronchodilatator in
dental office
• Adrenalin may trigger
• High risk for candida
Can cause hypocalcemia – tetany
Breath throught nose
No from bag – can cause suffocation
Calm down the patient
Diabetes mellitus
Oral manifestations:
Parodontal diseases
Delayed wound healing
Diabetes mellitus
Increase the risk of infection, necrosis
Microangiopathic changes
• Check the time of eating – treat after meal
• Keep appointments as short as possible
• Instruct your patient to eat before treatment as
• Before invasive treatment check the glucose level
Hypertensive emergency
• 220/140 is an acut danger (but quick increase also
• Pain in the chest
• Haedake
• Nausea
• Altered visus
• The symptoms are similar to hart or
celebrovascular attack
Hypotensive emergency
• Collapse – generally it isn’t serious
Position the patient in Trendelenburg
Fresh air
Be care not to fall
Patients with acut infectious
• Important to differentiate acute (influenza, herpes
simplex, etc.) and chronic infections (HIV, HBV,
• Acute infection – postpone the treatment if it is
possible or choose conservative therapy
Exception: pulpitis, periapical abscess
• Take into consideration applied medicines for the
basic disease.
Patients with chronical
infectious diseases
• The treatment may not be refused in the event of
an infectious disease!
• In most cases interaction with an HIV infected
patient’s blood or excretion does not lead to
• Accepting attitude – more information
• In case of an exposure it is vital to find the
serological status of the source of the infection.
Types of exposure
• Pierced or cut injuries with a contaminated
• Direct contact between mucosa or damaged skin
with blood or excretions
• Human bite
• Laboratory infection
• Exposure: pierced, cut or bited injuries, direct
contact on damaged skin with blood or excretion
• The probability of HIV infection in the event of
exposure is 0.3%.
• In connection to HBV and a vulnerable patient it is
6-30%, to HCV 1.8%
• Contact between a small amount of blood and
intact skin does not carry risk.
Treatment of a patient with an
infectious disease
• Should be called into the dentist’s surgery as the last
• Mouth hygiene has increased significance,
chlorhexidine mouth rinse
• In the event of invasive treatment antibiotic
prophylaxis may be necessary
• Protective equipment should be worn – mask, glasses,
gloves, rubber dam isolation
• Avoid the use of the turbine and ultrasonic depurator
if possible
• Desinfection must be performed as usual!!!
TBC (mycobacterium
• 2 million people die annualy from it
• Patients with open pulmonary TB is highly
contagious – urgent dental treatment only
• Prevent to release mycobacteria to the air
reduction of aerosols – turbine, ultrasound
depurator, ultraviolet germicidal light
• Personal protective devices are important
• Often infected with hepatitis, tuberculosis,
Patients with psychiatric
Paranoid patients
Agressive patients
Alzheimer disease
Risks related to drugs
Antikoagulant drugs
Drug interactions
Classic non-steroids
Indometacin, diclofenac, ibuprofen
• Classic NSAID-s inhibit primary COX-1 enzyme
• inhibit platelets
• gastric ulceration and bleeding
• Increase the effect of anticoagulant (replace in this
cases for paracetamol)
• Huge quantity sold – every day die one people
through gastric bleeding caused NSAIDS
• fokozza a kardiovascularis események gyakoriságát
• Increase the incidence of cardiovascular disorders
selective NSAID-s
Oxicamok, coxibok
Inhibit primary the COX-2 enzyme (pain,
inflammation, high temperature, but no
platelet function)
History of gastrointestinal bleeding prescript
only selective NSAIDS
Increase the risk of myocardial infarction
Drug interactions
• Drugs used in the dental office have many
interactions (NSAID’s, azols, antibiotics).
• The effect of a certain drug may rise to
a dangerous level
• A drug becomes ineffective
• Not desired, dangerous side effect may
Drugs containing adrenaline are
not recommended:
In case of tachycardia, severe arrythmia
MI within 6 months
Thyroid overfunction
Severe high blood pressure
Pregnancy with complications
Bad habits
Alcohol consumption
Spicy food
Summary - Important diseases
related to dental treatment
Infectious diseases
Autoimmun diseases
Cardiovascular diseases
Diabetes mellitus
Haematological diseases
Malignant diseases
Rheumatological diseases
Eating disorders
Psychiatrical disorders
Additional risks: abuses, pregnancy
Thanks for your attention