Download medeical Evaluation

MANAGEMENT OF MEDICALLY
COMPROMISED PATIENTS
The risks of any procedure can be increased by the
1. Health status o the patient
2. Complexity and duration of the case
3. Degree of invasiveness
4. Experience and skill of the operator
5. Addition of sedation or general anaesthesia
Status Classification for Dental Patients
American Society of Anesthesiologist (ASA)
Risk Status
Definition
Approach
I
No overt systemic condition/s
Routine office care
May require sedation
II
Mild /Moderate systemic diseases
Medically stable
Routine office care
Approach minor modification
III
Severe systemic condition/s
Medically fragile
Limited activity
Not debilitating
Emergency care
Medical consult
Modification
IV
Debilitating systemic conditions
Constant threat to life
Emergency care
Medical consult
Care in hospital environment
V
Morbid patient
Maintain basic life support
Not expected to live
Classification of Dental Treatment
Classification
Treatment
Type I
Examination, radiographs, study impressions, OHI, supragingival prophylaxis, simple restorative dentistry.
Type II
Sc.& RP, endodontics, simple extraction, curettage, simple
gingivectomy, advanced restorative procedures, simple
implant.
Type III
Multiple extraction, gingivectomy, Q. periosteal reflection,
impacted extractions, apicoectomy, plate form implants,
multiple root forms, ridge augmentation, unilateral sinus
graft, unilateral subperiosteal implants.
Type IV
Full arch implant (complete subperiosteal implants, ramus
frame implants, full arch endosteal implants),
orthognathic surgery, autogenous bone augmentation,
bilateral sinus graft.
Evaluation of Risk in Systemic Disease
Risk
Mild
ASA
II
Type I
Type 2
+
Sedation
Stress Reduction
Protocol
Moderate
III
+
Severe
IV
+
Type 3
Type 4
IV Sedation
Stress Reduction Protocol
IV Sedation
Stress Reduction Protocol
Physician
Hospitalization
Postpone All Elective Procedures
Medium Risk
Patient
Low Risk
High Risk
CARDIOVASCULAR DISEASES
Cardiovascular Diseases
Hypertension
Angina Pectoris
Myocardial Infarction
Infective Endocarditis
Congestive Heart failure
Previous Cardiac Bypass.
Previous Cerebrovascular Accident
Presence of Cardiac Peace Makers
Presence of prosthetic valve
Risk factors for
cardiovascular disease
 Smoking
 Excess alcohol
 Diabetes mellitus
 Hypercholesterolemia
 Lifestyle
 Obesity
It is important to assess
 Degree of compensation that the patient has
managed to achieve (signs and symptoms)
 The efficacy of medication
Remember:
The key issues for heart patient are pain control
and stress management
Hypertension
Hypertension
Dental
Tx for controlled hypertensive
Primary
Secondary
patient is safe except
No underlying
patient with stagesUnderlying
III - IV
Pathological C.
Pathological C.
95%
Normal Blood pressure is 120/80 mm Hg
Dentist should have a baseline level
Periodontal Management in Hypertensive Patient
Risk
Diastolic
mm Hg
Type I
Type 2
Type 3
Type 4
130-139
85-89
+
+
Sedation
Sedation
Hypertension 140-159
Stage I
90-99
+
Sedation
Sedation
Sedation
Sedation
Normal High
Systolic
mm Hg
Stage II
160-179
100-109
+
Postpone all Elective
Procedures
Stage III
180-209
110-119
Refer and postpone all elective procedures
Stage IV
≥ 210
≥ 120
Refer and postpone all elective procedures
Myocardial Infarction (MI)
Elective dental surgery on post-MI patient
Old Reports:
A 6 month waiting period for cardiac stability
Recently: Pt. ( medically determined ) isn't at risk
Surgery as early as 6 weeks after the event, with protocol
Complications in Hypertensive Patients
 Stressful situation may cause additional raise
in BP (Stroke, MI)
 Post –operative bleeding
 Interactions between patient`s
antihypertensive medication and other
medications.
 Consultation with the physician
 Patient assessment (risk factors)
 Emergency kit (Nitrate & Oxygen))
 Achievement of profound anesthesia
 Stress reduction measures (iv. Sedation)
 Preoperative pain medication
 Vital sign monitoring (blood pressure, heart rate)
Presence of Cardiac Peace Makers 
Avoid using ultrasonic and sonic instruments. 
Presence of prosthetic valves or valve 
diseases:
Antibiotic prophylaxis is important before 
dental procedure.
Endocrine Disorders
 Diabetes Mellitus
 Thyroid Disorders
 Adrenal Gland Disorders
 Pregnancy
THYROID DISEASES
Abnormality of the circulating level of thyroxine
due to overproduction (hyperthyroidism) or under
production (hypothyroidism)
Parathyroid hormones regulate the level of
calcium in the plasma by acting on the
kidney, gut and bone.
Hyperthyroidism may lead to loss of lamina
dura around the teeth.
Thyroid disease may present as a goiter.
Thyroid function should be stabilized before
dental treatment.
PTH,
It is hypercalcemic, removing the calcium ions
from bone and transferring them to circulating
blood.
It increases the urinary elimination of phosphates
by reducing their tubular reabsorption.
It contributes to maintaining an optimal calcemia
by intervening in the kidney’s physiologic tubular
reabsorption of calcium.
It plays an important role in the intestinal
absorption of calcium in synergy with vitamin D
Adrenal Insufficiency
Acute adrenal insufficiency is associated with significant
morbidity and mortality owing to peripheral vascular
collapse and cardiac arrest. Therefore the operator should
be aware of the clinical manifestations and ways of
preventing acute adrenal insufficiency in patients with
histories of primary adrenal insufficiency (Addison's
disease) or secondary adrenal insufficiency (most often
caused by use of exogenous glucocorticosteroids).
Management of the patient in an acute
adrenal insufficiency crisis
1. Terminate treatment.
2. Summon medical assistance.
3. Give oxygen.
4. Monitor vital signs.
5. Place the patient in a supine position.
6. Administer 100 mg of hydrocortisone sodium
succinate (Solu-Cortef) intravenously for 30 seconds
or intramuscularly.
Prolonged use of corticosteroids
Bone fragility
Renal deficiency
Metabolic disorders (blood sugar metabolism)
Water retention
Inhibition bone resorption
Prolonged use of corticosteroids
Determine ….
 Reason for treatment
 Patient’s response
Steroids act in three different ways that affect
periodontal surgery;
1.
2.
3.
They decrease inflammation and are useful in
decreasing swelling and related pain.
They decrease protein synthesis and therefor delay
healing.
They decrease leukocytosis and therefor reduce
patient’s ability to fight infection
Whenever steroids are prescribed to patients for
surgery, antibiotics should also be given.
Systemic complications of Diabetes
Mellitus
 Microvascular disease





Alteration in structure
Cardiovascular disease
Thickening of vascular wall
Arteriosclerosis
Stroke
Nephrology
Neuropathy
Retinopathy
Diabetes-Induced Changes in Bone
Formation
 Inhibition of collagen matrix formation
 Alterations in protein synthesis
 Increased time for mineralization of osteoid
 Reduced bone turn over
 Decreased number of osteoblasts and osteoclasts
 Altered bone metabolism
 Reduction in osteocalcin production
Surgical implant osteotomy
Blood clot formation
Bone resorption phase
Matrix formation phase
Bone deposition/
osteoid mineralization
Maintenance of
osseointegration
Changes in wound
healing proteins
Decreased number of osteoclast
Inhibition of collagen formation
Decreased number of osteoblast
Mineralization proteins reduced
Reduced bone turnover
Alterations in bone homeostasis
Change in diabetic status
Possible Risk Factors for the
Diabetic Patient in periodontics
 Type of onset
 Age of patient
 Elevated blood glucose levels
 Regimen of glycemic control
 History of tooth loss due to periodontitis
 Poor insufficient wound healing history
 Extent of edentulous
 Smoking as a cofactor for implant failure
Hematological Disorders
 Erythrocytic Disorders
Polycythemia
(splenic enlargement, hemorrahges , thrombosis of
peripheral veins).
Anemia
 Leukocyte Disorders
Leukemia
 Platelet & Coagulation Anomalies
Problems with red blood cells
Anemia
Reduction in the oxygen-carrying capacity of the blood and is
defined by a low value for hemoglobine
< 13.5 g/dl for men
< 11.5 g/dl for women
Severe Anemia
Hb < 7.0 g/dl
Poor Wound Healing
Thrombocytopenia
Seriously affect blood clotting.
Sever hematoma
Bleeding disorders may be classified as
Coagulation disorders
(hemophiliac A and B and von Willebrand's disease)
Thrombocytopenia (Platelet Disorders)
(Thrombocytopenia is defined as a platelet count <100,000/mm 3 ).
Vascular Disorders
Laboratory Tests
 Bleeding & Clotting T.
 Not sufficiently sensitive to
 Hemoglobin

 Platelet Count

 Prothrombin Time

 Partial thromboplastin time


be used as screening test.
Degree of anemia
Platelet deficiency
Plasma prothrombin level;
liver disease; defect in
coagulation factor
Defect in coagulation factors
Defects in capillary wall.
 Normal bleeding time 2.5 – 8.0 minutes
Severe bleeding more than 15 minutes
 Prothrombin time PT 11-14 seconds
 Partial thromboplastin time (PTT) 2.5-3.6
second
Normal Platelet Count 250.000 ±
100.000 cells/mm3
Spontaneous Bleeding 80.000 to
60.000 cells/mm3
 Gingival irritation
 Gingival Inflammation
Liver Diseases
 Liver is the site of production for most of the
clotting factors, excessive bleeding during or
after periodontal treatment may occur in
patients with severe liver disease.
 Many drugs are metabolized in the liver; thus
liver disease alters normal drug metabolism.
Treatment recommendations for patients
with liver disease include the following
1. Consultation with the physician concerning
current stage of disease, risk for bleeding,
potential drugs to be prescribed during
treatment, and required alterations to
periodontal therapy.
2. Screening for hepatitis B and C.
3. Check laboratory values for prothrombin
time and partial thromboplastin time.
Bone is the main calcium reservoir
of the body, and maintenance of a
proper serum calcium level is
essential for homeostasis.
Mineral Equilibrium:
 Kidney
 Liver
 Gastrointestinal
 Parathyroid disease
 Vitamin D deficiency
Kidney:
The most important calcium conserving organ in
the body.
Patients with < 50% normal kidney function
are at risk for surgery
Renal Dialysis
 Avoid drugs that are nephrotoxic or metabolized by





the kidney such as
Phenacetin, streptomycin, tetracycline
Extraction of all questionable teeth
Elimination all source of infection
Good oral hygiene
Prophylactic antibiotic coverage
Provide treatment on the day after dialysis, when the
effects of heparinization have subsided.
Vitamin D
 Vitamin D is synthesized in the skin in response to
ultraviolet light.

Vitamin D is hydroxylated in the liver and kidney to
produce to active metabolite of vitamin D, 1.25dihydroxycholecalcifero (1.25- DHCC),

Absorption of calcium from the small intestine is
accomplished by 1.25- DHCC.
Vitamin D Deficiency
Osteomalacia
Contraindication for Dental Implant
Poor healing potential
Unmineralized osteoid with inadequate strength
Osteoporosis
 A reduced weight per volume unite of bone,
without a modified mineral to organic matrix
ratio or any anomalies in either.
Osteoporosis
It is a negative balance of bone remodeling, resulting in
reduction in the quantity of bone (number & diameter of
trabecular bone) and a thinner cortex.
It occurs in postmenopausal women and elderly men,
resulting in bone trabeculae that are scanty, thin, and
without osteoclastic resorption.
Prosthetic Joint Replacement
The main treatment consideration for patients
with prosthetic joint replacements relates to
the potential need for antibiotic prophylaxis
before dental therapy.
Antibiotic Prohylaxices
Patient Characteristics
Drug Regimen
Patients not allergic to penicillins
Cephalexin, cephradine, or
amoxicillin: 2 g orally
1 hour before dental procedure
Patients allergic to penicillins
Clindamycin: 600 mg orally1 hour before
dental procedure
Patients not allergic to penicillins but
unable to take oral medication
Cefazolin 1 g or Ampicillin 2 g
intramuscularly or intravenously 1 hour
before dental procedure
Patients allergic to penicillins and unable Clindamycin 600 mg intralivenously 1
to take oral medications
hour before dental procedure (must be
diluted and injected slowly)
Medications of Interest to
periodontal surgery
 Anticoagulant Medications
 Bisphosphonates
 Immunosuppressive Medications
 Rheumatoid Arthritis
Patients on Anti-Coagulant Drugs
 Heparin
 Bishydroxycoumarin (Dicumarol)
 Warfarin sodium (Coumadin)
 Phenindione derivatives
 Cyclocumarol
 Ethyl biscoumacetate
 Aspirin
Warfarin
 Warfarin is administrated orally
 Action up to 6 days
Management of:
Atrial fibrillation ( as thromboembolic prophylaxis)
Deep vein thrombosis
Prevention of embolisation secondary to MI
After prosthetic heart valve replacement
The therapeutic efficacy is monitored using
the International Normalized Ratio (INR)
Test to Monitor Oral Anticoagulants
Patient's Prothrombin Time
INR =
Normal Prothrombin Time
Normal 1.0-1.3
During anticoagulant therapy, 2.5-3.0
Pt. with prosthetic heart valve 3.0-4.5
Aspirin
 0,5 to 1 mg /kg
 5 – 10 mg/kg
 30 mg/kg
antiplatelet effect
antipyretic effect
anti-inflammatory response
Bisphosphonates
Laboratory Risk
Assessment
C-telopeptides (CTx)
(fragments of collagen that are
released during bone
remodeling and turnover)
CTx Value
Risk for Osteonecrosis
300-600
None
150-299
None to minimal
101-149
Moderate
< 100
High
Immunosuppressive Medicated
Immunosuppressed patients have impaired host defenses as a result of an
underlying immunodeficiency or drug administration (primarily related to
organ transplantation or cancer chemotherapy).
Glucocorticoids (Prednisone)
Antibodies
Cytostatics (chemotherapeutic agents)
Immunophilins (cyclosporine)
Immunosuppressed individuals are at greatly increased risk for infection, and
even minor periodontal infections can become life threatening if immune
suppression is severe.
Chemotherapy is often cytotoxic to bone marrow, destruction of platelets and
red and white blood cells results in thrombocytopenia, anemia, and leukopenia
Radiation Therapy
Most severe among the resulting oral complications
is osteoradionecrosis (ORN).
Decreased vascularity renders the bone less capable of
resolving trauma or infection. Such events may
cause severe destruction of bone. The risk of ORN
continues for the remainder of the patient's life and
does not decrease with time
Flap surgery or extraction of teeth after radiation may lead
to ORN.
Hyperbaric oxygen therapy is frequently
required for complete resolution.
Pregnancy
 Second trimester is the safest time
 Do not perform long and stressful procedures
 Short appt.
 Changing position from time to time to avoid
hypotension.
 Fully reclined position should be avoided if
possible.
 No medication should be prescribed or
radiographs taken unless the situation is
emergency
 Consultation with obstetrician.