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MANAGEMENT OF medically compromised patients subtitle style Click to edit Master

SUBMITTED BYRAJAN CHAUDHARY(51) RUCHI TANEJA (54) 5/1/12

CONTENTS
CARDIOVASCULAR PROBLEMS

HYPERTENSION ISCHEMIC HEART DISEASE STROKE CONGESTIVE HEART FAILURES DIABETES MELLITUS ADRENAL INSUFFICIENCY HYPERTHYROIDISM HYPOTHYROIDISM

ENDOCRINAL DISORDERS

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HEMATOLOGICAL PROBLEMS

HEREDITARY COAGULOPATHIES THERAPEUTIC ANTICOAGULATION ASTHMA COPD RENAL DIALYSIS RENAL TRANSPLANT HEPATIC DISORDERS SEIZURES ETHANOLISM

Pulmonary problems

RENAL PROBLEMS

NEUROLOGICAL DISORDERS

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CARDIOVASCULAR PROBLEMS

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HYPERTENSION
Chronically elevated blood pressure for which the

cause is unknown is called essential hypertension

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MANAGEMENTMild to moderate hypertension (Systolic

>140; Diastolic >90)

Recommend that the patient seek the primary care

physicians guidance for medical therapy for hypertension

Monitor the patients blood pressure to each visit and

whenever administration of epinephrine- containing local anesthetic surpasses 0.04mg during a single visit
Use of anxiety reduction protocol Avoid rapid posture changes in patients taking drugs

that cause vasodilation

Avoid administration of sodium-containing 5/1/12

Severe hypertension (Systolic

>200; Diastolic >110)

Defer elective dental treatment until hypertension is

better controlled
Consider referral to oral and maxillofacial surgeon for

emergency problems

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ISCHEMIC HEART DISEASE

ANGINA PECTORIS: Obstruction of the arterial supply to the myocardium-

most common health problem

Primarily in men over 40 years of age, also prevalent in

post menopausal females

Basic disease process-

Progressive narrowing or spasm of one or more of the coronary arteries Discrepancy between the myocardial oxygen demand and 5/1/12 the ability of the coronary arteries to supply oxygen-

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 Angina is a symptom of ischemic heart disease The myocardium becomes ischemic, producing a

heavy pressure or squeezing sensation in the patients substernal region that can radiate into the shoulder and arm and into the mandibular region. nausea,sweating and bradycardia.

Stimulation of vagal activity commonly occurs with Preventive measures that will reduce the anginal

episode-

Taking a careful history of the

patients angina Question about the events that 5/1/12

 If angina arises during moderately vigorous

exertion, responds to oral nitroglycerin and no recent increase in severity- ambulatory oral surgery procedures are safe when performed with proper precautions.
If anginal episodes occur after minimal exertion,

several doses of nitroglycerin are needed, patient has unstable angina- elective surgery is deferred. oral surgery can safely proceed, increased oxygen demand result in patient anxiety.

Once decision is made that ambulatory elective

ANXIETY REDUCTION PROTOCOL

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is used.

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BEFORE APPOINTMENT
Hypnotic to promote sleep on night before surgery

(optional)

Sedative agent to decrease anxiety on morning of

surgery(optional)

Morning appointment and schedule so that reception

room time is minimized DURING APPOINTMENT

Non pharmacologic means of anxiety control

Frequent verbal reassurances 5/1/12 Distracting conversation

Pharmacologic means of anxiety control

Local anesthetics of sufficient intensity and duration Nitrous oxide Intravenous anxiolytics

After surgery
Succinct instructions for postoperative care Patient information on expected postsurgical sequelae

(e.g. swelling or minor oozing of blood)

Further reassurance Effective analgesics Patient information on who can be contacted if any 5/1/12

q Patient can be given supplemental oxygen and

premedicated nitroglycerin
q Profound anesthesia best means of limiting anxiety q Avoid excessive epinephrine administration by

using proper injection techniques

q Give no more than 4ml of local anesthetic solution

with a 1:100,000 concentration of epinephrine for a total adult dose of 0.04mg in any 30-minute period. vital signs

q Before and during surgery, periodically monitor the

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MYOCARDIAL INFARCTION: Occurs when ischemia causes cellular dysfunction and

death

Infarcted area of myocardium becomes nonfunctional

Eventually necrotic+ surrounded by an area of reversibly ischemic myocardium Prone to serve as a nidus for dysrrhythmias

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MANAGEMENTv Patients physician consultation v Elective major surgical procedures be deferred until at

least 6 months after an infarction

v Patients with a history of MI should be carefully

questioned regarding their cardiovascular health

v Elicit evidence of undiagnosed dysrrhythmias or CHF v Some patients take aspirin or other anticoagulants to

decrease coronary thrombogenesis, this information should be sought because it can affect surgical decision making

v Use anxiety reduction protocol 5/1/12

CEREBROVASCULAR ACCIDENT (STROKE)

Clearance by patients physician Delay until significant hypertensive tendencies have

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CONGESTIVE HEART FAILURE (HYPERTROPHIC CARDIOMYOPATHY):-

Occurs when diseased myocardium is unable

to deliver the cardiac output demanded by the body or when excessive demands are placed on a normal myocardium.
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Symptoms orthopnea, paroxysmal

nocturnal

dyspnea,
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MANAGEMENTDefer treatment until heart function has

been medically improved and physician believes treatment is possible

Use anxiety reduction protocol Possible administration supplemental oxygen Avoid supine position Consider referral to oral and maxillofacial

surgeon
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ENDOCRINE

DISORDERS

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DIABETE S MELLIT
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INSULIN- DEPENDENT DIABETES

Defer surgery until diabetes well controlled; consult

physician

Schedule an early morning appointment; avoid lengthy

appointment

Use anxiety reduction protocol, but avoid deep

sedation techniques in outpatients during, and after surgery 5/1/12

Monitor pulse, respiration, and blood pressure before,

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NON-INSULIN- DEPENDENT DIABETES

Defer surgery until diabetes is well controlled Schedule an early-morning appointment; avoid lengthy

appointments
Use an anxiety reduction protocol Monitor pulse, respiration and blood pressure before,

during and after surgery surgery

Maintain verbal contact with the patient during If patient can eat or drink before oral surgery and will

have difficulty eating after surgery, instruct patient 5/1/12 to skip any oral hypoglycemic medications that day

ADRENAL INSUFFICIENCY:-

Diseases of adrenal cortex may cause adrenal

insufficiency

Symptoms of primary adrenal insufficiency- weakness,

weight loss, fatigue and hyperpigmentation of skin and mucous membrane

Most common cause- chronic therapeutic 5/1/12

Patients have moon facies, buffalo

humps, and thin, translucent skin

Their inability to increase

corticosteroid levels in response to physiologic stress may cause them to become- hypotensive, syncopal, nauseated, feverish during complex, prolonged surgery
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MANAGEMENT-

If patient is currently on corticosteroids:

Use anxiety reduction protocol Monitor pulse and blood pressure before, during, and

after surgery
Instruct patient to double usual daily dose on the day

before, day of, and day after surgery

On second postsurgical day, advise the patient to return

to a usual steroid dose

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If the patient is not currently on steroids, but has received at least 20mg of hydrocortisone ( cortisol or equivalent) for more than 2 weeks within past year:
Use anxiety reduction protocol Monitor pulse and blood pressure before, during,

and after surgery

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 Instruct the patient to take 60mg of

hydrocortisone (or equivalent) the day before and the morning of surgery (or the dentist should administer 60mg of hydrocortisone or equivalent intramuscularly or intravenously before complex surgery.
On the first 2 postsurgical days, the dose should

be dropped to 40mg and dropped to 20mg for 3 days thereafter. The clinician can cease administration supplemental steroids 6 days after surgery.

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HYPERTHYROIDISM:v The thyroid problem of primary significance in oral

surgery is thyrotoxicosis because acute crisis can occur

v Result of an excess production circulating

triiodothyronine (T3) and thyronine(T4), caused in graves disease, multinodular goiter or thyroid adenoma

Early manifestations fine, brittle hair, hyperpigmentation of skin, 5/1/12

v Thyrotoxic patients usually treated

with agents that block thyroid hormone synthesis and release or with thyroidectomy or both.
v Patients left untreated or incompletely treated can

develop thyrotoxic crisis, caused

by sudden release of large quantities of preformed thyroid hormones.

v Early symptoms- restlessness, nausea, abdominal cramps v Later symptoms- high fever, diaphoresis, tachycardia

and eventually cardiac decompensation.

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MANAGEMENT-

Take complete medical history and perform a careful

examination of patient including thyroid inspection and palpation

If severe hyperthyroidism is suspected from history

and inspection, GLAND SHOULD NOT BE PALPATED because it may trigger a crisis
Patient with treated thyroid disease can safely undergo

ambulatory oral surgery

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HYPOTHROIDISM: Dentist play a role in initial recognition Early symptoms- fatigue, constipation, weight loss,

hoarseness, headaches, arthralgia, menstrual disturbances, edema, dry skin, brittle hair and fingernails therapy required

If symptoms are mild- no modification of dental

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HEMATOLOGIC PROBLEMS

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HEREDITARY COAGULOPATHIES:-

History of epistaxis, easy bruising, hematuria, heavy

menstrual bleeding and spontaneous bleeding should alert dentist

Specific factor deficiencies, such as, hemophilia A,B,C

or von Willibrand disease-managed by the perioperative administration of factor replacement and by use of an antifibrinolytic agent, such as
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MANAGEMENT-

Defer surgery until a hematologist is consulted about

the patients management

Obtain baseline coagulation test as indicated

(prothrombin time, partial thromboplastin time, Ivy bleeding time, platelet count) and a hepatitis screen

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THERAPEUTIC ANTICOAGULATION:q Administered in patients with thrombogenic

implanted devices, such as prosthetic heart valves; with thrombogenic cardiovascular problems such as arterial fibrillation or post-MI; or with a need for extracorporeal blood flow, such as for hemodialysis properties, such as aspirin, as a secondary effect
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q Patient may also take drugs with anticoagulant

qMANAGEMENTPatients Receiving Aspirin or Other Platelet- Inhibiting Drugs

Consult physician to determine the safety of

stopping the anticoagulant drug for several days drugs have been stopped for 5 days

Defer surgery until the platelet- inhibiting

Take extra measures during and after surgery to

help promote clot formation and retention

Restart drug therapy if no bleeding is present
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Patients Receiving Warfarin (Coumadin)

1. Consult the patients physician to determine the

safety of allowing the PT to fall to 1.5 INR for few days

2. Obtain the baseline PT 3. a)If the patient is 1 to 1.5 INR, proceed with surgery

and skip to step 6

4.

b) If the PT is more than 1.5 INR, do to step 4

5. Stop warfarin approximately 2 days before surgery 6. Check the PT daily and proceed with surgery on the
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day when the PT falls to 1.5 INR

Patients Receiving Heparin

Consult the patients physician to determine the

safety of stopping heparin for the perioperative period heparin is stopped or reverse heparin with protamine

Defer surgery until atleast 6 hours after the

Restart heparin once a good clot has formed

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PULMONARY PROBLEMS

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ASTHMA-

Involves episodic narrowing of small airways which

produces wheezing and dyspnea as a result of chemical, infectious, immunologic, or emotional

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Question specifically about aspirin allergy because of

the relatively high frequency of NSAIDS allergy in asthmatic patients.

Patients with severe asthma- require Xanthine-

derived bronchodilators like theophylline and corticosteroids.

Cromolyn sodium- protect against acute
attacks but is ineffective once bronchospasm occurs.

Sympathomimetic amines such as,

epinephrine or metaproterenol in an aerosol form can be self-administered if wheezing begins.
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MANAGEMENT Defer dental treatment until asthma is well controlled

and patient has no signs of a respiratory tract infection

Listen to chest with stethoscope to detect wheezing

before major oral surgical procedures or sedation

Use reduction protocol, including nitrous oxide but avoid

use of respiratory depressants

Consult physician about possible use of

preoperative cromolyn sodium

If patient is or has been chronically on

corticosteroids, prophylax for adrenal insufficiency

Keep a bronchodilator- containing inhaler easily

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE: Caused by long-term exposure to pulmonary irritants,

such as, tobacco smoke, that cause metaplasia of pulmonary airway Airways are disrupted Lose their elastic properties Become obstructed because of mucosal edema, excessive secretions and bronchospasm
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MANAGEMENT
Bronchodilators like theophylline are

prescribed
Severe cases corticosteroids are given Only in most severe chronic cases-

supplemental portable oxygen is used

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MANAGEMENT Defer treatment until lung function has improved and

treatment is possible
Listen to chest bilaterally with stethoscope to determine

adequacy of breath sounds

Use anxiety reduction protocol, but avoid use of

respiratory depressants
If patient is on chronic oxygen supplementation, continue

at prescribed flow rate. If patient is not on supplemental oxygen therapy, consult physician before administering oxygen
If patient chronically receives corticosteroid therapy,

manage patient for adrenal insufficiency

5/1/12 Avoid placing patient in supine position until confident

RENAL PROBLEMS
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RENAL DIALYSIS:MANEGEMENTv Avoid the use of drugs the renal metabolism or

excretion. Modify the dose if such drugs are necessary antiinflammatory drugs

v Avoid use of nephrotoxic drugs, such as nonsteroidal v Defer dental care until the day after dialysis has

been given
v Consult physician concerning use of prophylactic

antibiotics
v Monitor blood pressure and heart rate 5/1/12

RENAL TRANSPLANT AND TRANSPLANT OF OTHER ORGANS:MANAGEMENTv Defer treatment until primary care physician or v Avoid use of nephrotoxic drugs. v Consider use of supplemental corticosteroids. v Monitor blood pressure.

transplant surgeon clears patient for dental care.

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v Consider hepatitis B screening before dental care.

Take hepatitis precautions if unable to screen for hepatitis

v Watch for presence of cyclosporine A-induced

gingival hyperplasia. Emphasize importance of oral hygiene particularly for patients on immunosuppressive agents

v Consider use of prophylactic antibodies,

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HEPATIC DISORDERS

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IMPAIRED LIVER FUNCTION:o Severe liver damage resulting from

infectious disease, ethanol abuse or vascular or biliary congestion requires special consideration before oral surgery is performed

o MANAGEMENT Attempt to learn the cause of the liver problems; if

the cause is hepatitis B, take usual precautions

Avoid drugs requiring hepatic metabolism or excretion;

if their use is necessary, modify dose

Screen patients with severe liver disease for bleeding 5/1/12

NEUROLOGIC DISORDERS

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SEIZURE DISORDERS:q Patients with a history of seizure should be questioned

about the frequency, type, duration and sequelae of seizures hypoglycemia, or traumatic brain damage or can be idiopathic.

q Can result from ethanol withdrawal, high fever,

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qMANAGEMENTv Defer surgery until the seizures are well

controlled

v Consider having serum levels of antiseizure

medications measured if patient compliance is questionable

v Use anxiety reduction protocol v Avoid hypoglycemia and fatigue 5/1/12

 ETHANOLISM (ALCOHOLISM):-

Primary problems ethanol abusers have in relation to

dental care are

Hepatic insufficiency Ethanol and medication interaction Withdrawal phenomena anxiety reduction protocol 5/1/12

Ethanol interacts with many of the sedatives used for

 Ethanol abusers may undergo withdrawal

phenomenon in the perioperative period if they hav acutely lowered their daily ethanol intake before seeking dental care.
Phenomenon exhibit- mild agitation, tremors,

seizure, diaphoresis.
Rarely, delirium tremens with hallucinations,

marked agitation and circulatory collapse.

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 Patients exhibiting signs of severe alcoholic liver

disease or signs of ethanol withdrawal- should be treated in the hospital setting consultation before surgery are desirable

Liver function tests, a coagulation profile, medical In patients treated on an ambulatory basis, dose of

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drugs metabolize in the liver should be altered and patients should be monitored closely for signs of oversedation

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