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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.