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Management of medically compromised patients

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Management of medically compromised patients

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Management of medically compromised patients

  1. 1. Dr.Elhawary Management of Medically compromised patients Management Of Medically Compromised Patients Hesham El-Hawary Associate Prof OMFS www.elhawarydentalclinic.com
  2. 2. Dr.Elhawary Management of Medically compromised patients Importance 1. Recognition of existing medical condition 2. Adequate preparation – Premedication – Prophylaxis – Adjustment – Prepare for any adverse effects 3. Postoperative consideration to control – Bleeding – Infection
  3. 3. Dr.Elhawary Management of Medically compromised patients Patients Classification According to their physical condition According to the American Society of Anesthesiologists (ASA) Type I : Normal patient Type II : Mild to moderate systemic disease Type III: Sever systemic disease limiting patient activity Type IV: Sever systemic disease threatening life Type V : Morbid patient
  4. 4. Dr.Elhawary Management of Medically compromised patients Treatment options 1. Office treatment • ASA type I • ASA type II 2. Hospitalization • ASA type III 3. Hospitalization and emergency treatment only • ASA type IV 4. Hospitalization and palliative treatment • ASA type V
  5. 5. Dr.Elhawary Management of Medically compromised patients Stress Reduction Protocol • Before appointment 1. Night before surgery Sleeping bills (Valium 5-10 mg) optional 2. Day of surgery Short acting barbiturates ( secobarbital 50 -100 mg ) optional 3. Early appointment 4. Short appointment
  6. 6. Dr.Elhawary Management of Medically compromised patients Stress Reduction Protocol cont. • During appointment 1. Relaxing background music 2. Reassurance 3. No surprises 4. No unnecessary noise 5. Surgical instruments out of patient sight 6. Profound local anesthesia 7. IV sedation optional 8. Nitrous oxide sedation optional
  7. 7. Dr.Elhawary Management of Medically compromised patients Stress Reduction Protocol cont. • After surgery 1. Further reassurance 2. Detailed information about expected postoperative sequelae 3. Effective analgesics 4. Telephone call for the patient at home
  8. 8. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES CARDIAC ARRHYTHMIAS ANGINA PECTORIS CORONARY ANGIOPLASTY MYOCARDIAL INFARCTION CORONARY ARTERY BYPASS GRAFTING RHEUMATIC HEART DISEASE HYPERTENSION Management of patients with systemic diseases
  9. 9. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES CARDIAC ARRHYTHMIAS Management of patients with systemic diseases
  10. 10. Dr.Elhawary Management of Medically compromised patients • Condition: 1. Abnormal pulse rate or rhythm 2. Cardiac pacemaker • Dental Management Considerations : 1. Consultation 2. Stress reduction protocol 3. Local anesthesia without vasoconstrictor (↑ arryhthmia) 4. Avoid diathermy and ultrasonic scaler in case of pacemaker 5. In case of decreased heart rate →direct vigorous thumbing on the pericardium 6. In case of rapid heart beats → Vagal stimulation through carotid sinus massage
  11. 11. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES ANGINA PECTORIS Management of patients with systemic diseases
  12. 12. Dr.Elhawary Management of Medically compromised patients • Condition: – Temporary inability of the coronary arteries to supply the heart musculature by oxygenated blood – Patient suffers from • substernal pain radiates to the left shoulder • Down to the fingers • May radiate to the neck and jaws – It always follows exercise, overeating, emotional stress and cold weather and fear due to increased levels of epinephrine and nor epinephrine – If lasts more than 30 minutes → Myocardial infarction
  13. 13. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consultation 2. Advise the patient to eat lightly before appointment 3. Premedication with short acting barbiturate 4. Stress reduction protocol 5. Nitroglycerine tablets sublingually • 5 min before stressful procedure • Keep it handy 6. Monitor vital signs 7. Avoid prolonged procedures 8. Avoid painful stimuli
  14. 14. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations: Cont. – Injection of LA containing V.C. IF NO V.C . → PAIN → endogenous adrenaline  safe suggestion 2 carpules containing max 1:100.000 adrenaline – Injection given very slowly + aspiration is a MUST – In case of unstable angina postpone the regular procedures, only emergency dental care should be performed
  15. 15. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES CORONARY ANGIOPLASTY Management of patients with systemic diseases
  16. 16. Dr.Elhawary Management of Medically compromised patients • Condition: Introduction of catheter containing balloon in narrowed coronary arteries • Dental Management Considerations : – The same precautions for Angina pectoris – Anticoagulant drug management i. Never withdrawal of anticoagulants (rebound thrombosis ) ii. Reduce the dose of oral anticoagulant to maintain prothrombin time 1.5 to 2 times the control (e.g. 25 second normal 15 second)
  17. 17. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES MYOCARDIAL INFARCTION CORONARY THROMBOSIS (PATIENTS ON ANTICOAGULANTS) Management of patients with systemic diseases
  18. 18. Dr.Elhawary Management of Medically compromised patients • Condition : – Anginal attack lasts more than 30 minutes – Patient experiences sever substernal pain and may go into shock and cardiac dysfunction that can lead to death • Clinical features: – Prolonged anginal pain last more than 30 minutes – Tachycardia and irregular pulse – Nausea and vomiting – Difficulty in breathing (pulmonary edema) – Pallor with symptoms of shock
  19. 19. Dr.Elhawary Management of Medically compromised patients • Treatment: 1. Complete physical and mental rest 2. Morphine as pain killer 3. Anticoagulant therapy to diminish thromboembolic complications N.B. Penicillin antagonize the anticoagulant effect of heparin • Emergency treatment 1. Call emergency unit 2. CPR 3. Emergency oxygen 4. IM 10% lidocain 5. Nitroglcerin sublingually 6. IV thrombolytic agent injection (streptokinase)
  20. 20. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consultation and Advise hospitalization 2. Postpone elective surgery till after 6 months 3. Prophylactic coronary dilators 4. Anticoagulant drug management i. Never withdrawal of anticoagulants ( fear of rebound thrombosis ) ii. Reduce the dose of oral anticoagulant to maintain prothrombin time 1.5 to 2 times the control (e.g. 25 second normal 15 second) 5. Stress reduction protocol 6. Monitor vital signs
  21. 21. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 7. Decrease the amount of adrenaline 8. Local haemostatic measures i. Constant pressure ii. Gel foam in the socket after extraction iii. Multiple sutures under tension iv. Heavy bite pressure 1 hour at least v. Ice Packs 1/2 hr on 1/2 hr off applied externally 9. Avoid mouth rinses and Hot liquids for 72 hrs
  22. 22. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES CORONARY ARTERY BYPASS GRAFTING Management of patients with systemic diseases
  23. 23. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Postpone elective surgery till after 6 months 2. Same as myocardial infarction 3. For the first 6 months, patients may need preoperative antibiotic prophylaxis against infective endocarditis
  24. 24. Dr.Elhawary Management of Medically compromised patients CARDIOVASCULAR DISEASES RHEUMATIC HEART DISEASE Management of patients with systemic diseases
  25. 25. Dr.Elhawary Management of Medically compromised patients • Condition : – Disease of altered immunological reaction to group A Beta- hemolytic streptococcal infection – The valves are frequently the site of subsequent Bacterial Endocarditis (SBE) – The most affected valves are the Mitral valve and the Aortic valve subsequently • Clinical features: 1. Septicemia 2. Petecheal haemorrhage 3. Finger clubbing – nail bed haemorrhage 4. Embolic complications in kidneys, brain, eyes 5. Cardiac failure
  26. 26. Dr.Elhawary Management of Medically compromised patients • Mortality rate: – 100% without antibiotic treatment – 10-65% for trerated patients • Treatment : – Prohylactic antibiotic against BE utilizing – Cardiac surgery with prosthetic valve replacement
  27. 27. Dr.Elhawary Management of Medically compromised patients • Dental treatment consideration: 1. Careful history 2. Medical consultation 3. Adjusting the anticoagulant therapy 4. Antibiotic coverage 5. Antiseptic mouth wash 6. Local anesthesia with vasoconstrictor to minimize bacteraemia 7. Atraumatic dental procedure 8. Two weeks is the minimum Interval between sessions
  28. 28. Dr.Elhawary Management of Medically compromised patients • Antibiotic regimen – Standard routine • Amoxycillin 2 grams orally 1 hour before procedure • For children 50 mg/kg orally 1 hour before procedure – Unable to take oral medications • Ampicillin 2 grams (IV/IM) 30 minutes before procedures • For children 50 mg/kg (IV/IM) 30 minutes before procedures
  29. 29. Dr.Elhawary Management of Medically compromised patients • Antibiotic regimen cont. – Allergic to penicillin • Clindamycin 600 mg orally1 hour before the procedures • For Children 20 mg/kg orally 1 hour before the procedures – Allergic to penicillin and unable to take oral medication • Clindamycin 600 mg (IM/IV)30 minutes before the procedures • For Children 20 mg/kg orally 1 hour before the procedures
  30. 30. Dr.Elhawary Management of Medically compromised patients HYPERTENSION Management of patients with systemic disease
  31. 31. Dr.Elhawary Management of Medically compromised patients • Condition: 1. The sum of COP, Blood volume, blood viscosity and vessel elasticity 2. It is related to cardiovascular diseases, renal diseases and atherosclerosis 3. Early signs: i. Breathlessness ii. Spontaneous nose bleeding iii. Persistent headache iv. Occular complaints v. General malaise and dizziness vi. Odontalgia with no local causes due to pulp hyperemia
  32. 32. Dr.Elhawary Management of Medically compromised patients • Classification of Hypertension According to etiology • Primary hypertension (Idiopathic) • Secondary hypertension – Renal disease – Adrenal cortical hyperfunction – CNS lesion According to its severity • Normal blood pressure 120-140/85-90 • Mild hypertension 140-160/90-105 mmhg • Moderate hypertension 160-200/105-114 mmhg • Sever hypertension >200/115 mmhg
  33. 33. Dr.Elhawary Management of Medically compromised patients • Complications: – Patients with undetected hypertension may account for occasional sudden death – Due to elevation of the blood pressure that leads to  Cerebral hemorhage  Myocardial infarction  Renal failure  Heart failure
  34. 34. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations: A. Mild to moderate hypertension: 1. Consultation 2. Stress reduction protocol 3. Monitor blood pressure 4. Decrease the amount of adrenaline (LA + VC (1/100,000)) 5. Inject anesthesia slowly and avoid intravascular injection 6. local haemostatic measures carefully taken to avoid undue hemorrhage 7. Avoid rapid posture changes that can leads to Orthostatic hypotension and syncope
  35. 35. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations: B. Severe hypertension >200/115 1. Consultation 2. Postpone till blood pressure is controlled 3. On emergency basis hospitalization 4. Premedication 5. Decrease the amount of adrenaline (LA + VC (1/200,000)) 6. local haemostatic measures carefully taken to avoid undue hemorrhage
  36. 36. Dr.Elhawary Management of Medically compromised patients HEMATOLOGIC DISEASE DISEASES OF RBCS ANEMIA DISEASES OF WBCS LEUKEMIA HEMORRHAGIC DISEASES HAEMOPHILIA Management of patients with systemic diseases
  37. 37. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS RBCS DISORDERS ANEMIA Management of patients with systemic diseases
  38. 38. Dr.Elhawary Management of Medically compromised patients • Definitions • Anemia – Deficient RBCs production – Decreased RBCs count – Decreased hemoglobin level • Complications – Not withstand blood loss • Heart failure • Myocardial infarction – Postoperative hemorrhage – Sore tongue
  39. 39. Dr.Elhawary Management of Medically compromised patients • Dental management consideration 1. Medical consultation 2. Complete blood picture 3. Postpone surgery if hg concentration is less than 10g/100ml 4. Search for the signs and symptoms of anaemia • sore tongue • necrotizing ulceration of the gingiva • bleeding during examination 5. Consider iron and multivitamin therapy preoperatively to increase haemoglobin synthesis 6. Local haemostatic measures and prophylactic antibiotic therapy to prevent postoperative infection should be provided
  40. 40. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS WBCS DISORDERS LEUKEMIA Management of patients with systemic diseases
  41. 41. Dr.Elhawary Management of Medically compromised patients • Conditions Progressive overproduction of immature WBCs in the blood • Features 1. Gingival bleeding 2. Ulceration of oral mucosa
  42. 42. Dr.Elhawary Management of Medically compromised patients • Dental management consideration 1. Medical consultation 2. Complete blood picture 3. Hospitalization 4. Search for the signs and symptoms of WBC disorders 5. Withdraw any systemic drug cause the condition 6. In cases need prolonged antibiotics periodic check-up by blood picture is a must 7. Extraction is contraindicated unless under strict conditions 8. Local haemostatic measures and prophylactic antibiotic therapy to prevent postoperative infection should be provided
  43. 43. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS HEMATOLOGIC DISEASES HAEMOPHILIA Management of patients with systemic diseases
  44. 44. Dr.Elhawary Management of Medically compromised patients Disease involving blood factors 1. Haemophilia – Haemophilia A (factor VIII) – Haemophilia B (Christmas disease factor IX) – Haemophilia C (plasma thromboplastin antecedent deficiency) 2. Pseudohaemophilia (factor VII) 3. Parahaemophilia (factor V) 4. Hypofibrinogenamia (factor I) 5. Hypoprothrombinaemia (prothrombin factor II)
  45. 45. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 1. Consultation 2. Laboratory investigations Pt, ptt, INR, platelet count and bleeding time 3. Hospitalization 4. Replacement of the deficient factor or platelet replacement (pre/post operatively)
  46. 46. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 5. Avoid nerve block techniques 6. Avoid major surgical procedures 7. Utilize atraumatic surgical protocol as possible 8. Local haemostatic measures • Obliteration of the dental socket with absorbable haemostatic materials – Gel foam soaked with thrombin/fibrinogen – Oxidized cellulose • Using cryotherapy or electrocoagulation • Suturing of the mucosa • Application of astringents
  47. 47. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 9. Careful postoperative instruction 10.Postoperative blood transfusion 11.No NSAIDs 12.High infection control measures 13.Discharge the patient after 3 days without bleeding
  48. 48. Dr.Elhawary Management of Medically compromised patients HEMATOLOGIC DISEASE DISEASES OF RBCS ANEMIA DISEASES OF WBCS LEUKEMIA HEMORRHAGIC DISEASES DISEASES INVOLVING PLATELETS DISEASES INVOLVING BLOOD FACTORS Management of patients with systemic diseases
  49. 49. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS RBCS DISORDERS ANEMIA Management of patients with systemic diseases
  50. 50. Dr.Elhawary Management of Medically compromised patients • Definitions • Anemia – Deficient RBCs production – Decreased RBCs count – Decreased hemoglobin level • Complications – Not withstand blood loss • Heart failure • Myocardial infarction – Postoperative hemorrhage – Sore tongue
  51. 51. Dr.Elhawary Management of Medically compromised patients • Dental management consideration 1. Medical consultation 2. Complete blood picture 3. Postpone surgery if hg concentration is less than 10g/100ml 4. Search for the signs and symptoms of anaemia • sore tongue • necrotizing ulceration of the gingiva • bleeding during examination 5. Consider iron and multivitamin therapy preoperatively to increase haemoglobin synthesis 6. Local haemostatic measures and prophylactic antibiotic therapy to prevent postoperative infection should be provided
  52. 52. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS WBCS DISORDERS LEUKEMIA Management of patients with systemic diseases
  53. 53. Dr.Elhawary Management of Medically compromised patients • Conditions Progressive overproduction of immature WBCs in the blood • Features 1. Gingival bleeding 2. Ulceration of oral mucosa
  54. 54. Dr.Elhawary Management of Medically compromised patients • Dental management consideration 1. Medical consultation 2. Complete blood picture 3. Hospitalization 4. Search for the signs and symptoms of WBC disorders 5. Withdraw any systemic drug cause the condition 6. In cases need prolonged antibiotics periodic check-up by blood picture is a must 7. Extraction is contraindicated unless under strict conditions 8. Local haemostatic measures and prophylactic antibiotic therapy to prevent postoperative infection should be provided
  55. 55. Dr.Elhawary Management of Medically compromised patients BLOOD DYSCRASIAS HEMATOLOGIC DISEASES HAEMOPHILIA Management of patients with systemic diseases
  56. 56. Dr.Elhawary Management of Medically compromised patients Disease involving blood factors 1. Haemophilia – Haemophilia A (factor VIII) – Haemophilia B (Christmas disease factor IX) – Haemophilia C (plasma thromboplastin antecedent deficiency) 2. Pseudohaemophilia (factor VII) 3. Parahaemophilia (factor V) 4. Hypofibrinogenamia (factor I) 5. Hypoprothrombinaemia (prothrombin factor II)
  57. 57. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 1. Consultation 2. Laboratory investigations Pt, ptt, INR, platelet count and bleeding time 3. Hospitalization 4. Replacement of the deficient factor or platelet replacement (pre/post operatively)
  58. 58. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 5. Avoid nerve block techniques 6. Avoid major surgical procedures 7. Utilize atraumatic surgical protocol as possible 8. Local haemostatic measures • Obliteration of the dental socket with absorbable haemostatic materials – Gel foam soaked with thrombin/fibrinogen – Oxidized cellulose • Using cryotherapy or electrocoagulation • Suturing of the mucosa • Application of astringents
  59. 59. Dr.Elhawary Management of Medically compromised patients • DENTAL MANAGEMENT CONSIDERATIONS: 9. Careful postoperative instruction 10.Postoperative blood transfusion 11.No NSAIDs 12.High infection control measures 13.Discharge the patient after 3 days without bleeding
  60. 60. Dr.Elhawary Management of Medically compromised patients PULMONARY DISEASES BRONCHIAL ASTHMA CHRONIC OBSTRUCTIVE PULMONARY DISEASE Management of patients with systemic diseases
  61. 61. Dr.Elhawary Management of Medically compromised patients PULMONARY DISEASES BRONCHIAL ASTHMA Management of patients with systemic diseases
  62. 62. Dr.Elhawary Management of Medically compromised patients • Condition: – Spontaneous reversible spasmodic contraction of the smooth muscles of the bronchioles – Dyspnea, wheezing and cough • Etiology : 1. Allergy 2. Viral infection 3. Familial
  63. 63. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consultation 2. Stress reduction protocol 3. Prophylaxis for adrenal insufficiency (under steroid) 4. Preoperative bronchodilators (Theophiline) 5. Oxygen 6. Patients on theophylline avoid prescribing: Asprin, NSAIDs, Barbiturates, Narcotics, sulfite containing preservative anesthetics, Erythromycine antibiotics 7. In more severe attack: i. Aminophyline 250 mg IV very slowly ii. Hydrocortisone 100 mg IV very slowly iii. Oxygen
  64. 64. Dr.Elhawary Management of Medically compromised patients PULMONARY DISEASES CHRONIC OBSTRUCTIVE PULMONARY DISEASE Management of patients with systemic diseases
  65. 65. Dr.Elhawary Management of Medically compromised patients • Condition: – Bronchitis associated with excessive mucous secretion, cough and expectoration • Etiology : 1. Smoking 2. Environmental pollutants
  66. 66. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consultation 2. Schedule afternoon appointments to allow respiratory clearance 3. Stress reduction protocol 4. Avoid premedication with narcotics or barbiturates as they are respiratory depressants 5. Keep bronchodilator inhaler accessible 6. Place the patient in the dental chair in an upright position 7. Avoid bilateral palatal or mandibular nerve blocks to avoid the sensation of respiratory obstruction
  67. 67. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 8. Use of rubber dam is not advised 9. Patients on oxygen, should be continued during surgery 10. Prophylaxis for adrenal insufficiency, if the patient is under steroid treatment 11. Avoid antihistaminics & Atropine as they lead to dry mouth and increase mucous production
  68. 68. Dr.Elhawary Management of Medically compromised patients ENDOCRINAL CONDITIONS DIABETES MELLITUS HYPERTHYROIDISM ADRENAL INSUFFICIENCY Management of patients with systemic diseases
  69. 69. Dr.Elhawary Management of Medically compromised patients ENDOCRINAL CONDITIONS DIABETES MELLITUS Management of patients with systemic diseases
  70. 70. Dr.Elhawary Management of Medically compromised patients • Condition: Chronic complex disease with metabolic and vascular components – Metabolic component: Disorder in the metabolism of insulin, carbohydrates, proteins and fats leads to elevation of blood glucose level – Vascular component • Atherosclerosis • Microangiopathy of small vessels
  71. 71. Dr.Elhawary Management of Medically compromised patients • Condition: Susceptibility to infection may be due to: 1. Hyperglycemia 2. Vascular insufficiency 3. Ketoacidosis 4. Neuropathy Normal Blood glucose level Fasting < 125 mg/dl
  72. 72. Dr.Elhawary Management of Medically compromised patients • Diabetes is controlled by: 1. Diet 2. Diet & oral Hypoglycemic drugs 3. Diet & Insulin N.B. patients controlled by diet and/or oral hypoglycemics are non insulin dependant patients (diabetes type II) while patients controlled by insulin are the insulin dependant patients (Diabetes type I)
  73. 73. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consultation Uncontrolled cases should be refereed for the physician and only emergency treatment could be performed 2. Stress reduction protocol 3. Dental procedures are best performed in the morning 90 – 180 min after breakfast and insulin usual dose since it is the hours of the descending part in blood sugar level 4. In non-insulin controlled patients all dental procedures could be performed 5. Prophylactic antibiotic administration the day before & 2-3 days after surgery (in case of massive surgery)
  74. 74. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 6. Adjustment of the insulin dose preoperatively: i. Normal postoperative feeding and Minimal surgical intervention → do not change the dose ii. Moderate surgical intervention that may affect the postoperative feeding → Patient should take half the dose before surgery iii. If the diet will be completely restricted postoperatively → Normal diet in the morning + No insulin intake
  75. 75. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 7. Use smallest amount of epinephrine in LA (not more than 1/ 100, 000) Or preferably use CORBASIL / octapresine since it's effect is only 1/10 of epinephrine in raising the blood sugar 8. If there is any doubt of insulin shock / Diabetic coma → IV dextrose if diabetic coma → no harm if insulin shock → dramatic correction 9. Sugar should always be available if hypoglycemic shock occur
  76. 76. Dr.Elhawary Management of Medically compromised patients Diabetic Coma and Insulin Shock Hypoglycemia Insulin Shock Hyperglycemia Diabetic coma Item Drowsiness and loss of consciousnessConsciousness moist & paledry & flushedSkin appearance ------------------IntenseThirst NormalAcetoneBreath odor RareCommonVomiting
  77. 77. Dr.Elhawary Management of Medically compromised patients ENDOCRINAL CONDITIONS HYPERTHYROIDISM THYROTOXICOSIS /TOXIC GOITER / GRAVE’S DISEASE Management of patients with systemic diseases
  78. 78. Dr.Elhawary Management of Medically compromised patients • Condition : – Increase secretion of thyroid hormones (T3, T4) in the circulation that can lead to thyroid crisis • Signs and symptoms of thyrotoxicosis: 1. Increased apatite and loss of weight 2. Warm moist skin 3. Irritability and nervousness 4. Fine tremors and muscle weakness 5. Increased cardiac output, pulse rate and blood pressure 6. Tachycardia 7. Dyspnea on exertion 8. Exophtalmous
  79. 79. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations (Prevention of thyroid crisis): 1. Medical Consultation 2. Postpone surgery until thyroid dysfunction is well controlled (1-2 months after controlling the case) 3. Stress reduction protocol 4. Avoid the use of vasoconstrictor i. Use plain anesthesia ii. Use local anesthesia with vasoconstrictor other than Adrenaline / Noradrenaline 5. Avoid Atropine as it may lead to thyroid crisis
  80. 80. Dr.Elhawary Management of Medically compromised patients Thyroid Crisis • Early symptoms of thyroid crisis 1. Restlessness 2. Nausea 3. Abdominal cramps • Late symptoms of thyroid crisis 1. High fever 2. Tachycardia 3. High pulse rate with severe hypotension 4. Tachypnea due to pulmonary oedema 5. Coma and heart failure
  81. 81. Dr.Elhawary Management of Medically compromised patients Thyroid Crisis cont. • Management of thyroid crisis: 1. Urgent call for medical aid 2. Cold packs to decrease temperature 3. Oxygen 4. Cardiopulmonary resuscitation 5. 100-300 mg hydrocortisone IV 6. Anti-thyroid medications e.g. potassium iodide or 200 mg propranolol 7. IV fluid as a supportive measures
  82. 82. Dr.Elhawary Management of Medically compromised patients ENDOCRINAL CONDITIONS ADRENAL INSUFFICIENCY ADDISON'S DISEASE Management of patients with systemic diseases
  83. 83. Dr.Elhawary Management of Medically compromised patients • Adrenal suppression can be caused by : 1. Addison’s disease ( 1ry ) 2. 2ry deficiency i. Pituitary or Hypothalamic disease ii. Prolonged corticosteroid therapy • Adrenal cortical suppression should be suspected if patient Take (RULE OF TWO) 1. 20 mg or more of cortisone daily 2. 2 weeks or more 3. within last 2 years
  84. 84. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations: 1. Medical Consultation 2. Adjust the corticosteroid dose Emergency Patients who are under corticosteroid therapy Patient who has taken corticosteroids in the last 2 years 125 mg of Solu- Medrol ( hydrocortisone ) is given IV at the time of surgery Normal dose is doubled for 2 days following ttt 1.Double or triple the dose day before surgery 2.Day of surgery 3.2 days postoperatively 4.Reinstitute normal dose after that 1. Reinstitute the previous dose of corticosteroid 2 days before the day of surgery 2. Continue the steroid therapy for one week postoperatively Management
  85. 85. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations: 3. Stress reduction protocol 4. Antibiotic therapy if extensive surgical procedures are anticipitated or if one is operating in an infected surgical field 5. GA is preferable for major surgeries 6. Preparation of the patient for General Anesthesia: 1. IM 100 mg hydrocortisone Night before operation 2. Repeat the dose immediately before operation 3. Sometimes anesthetist give IV drip ( cortisone ) during operation time 4. Post operatively (Tapering) 1. 50 mg hydrocortisone after recovery 2. 1.5 – 2 times the normal oral dose on the 2nd day 3. Normal dose on the 3rd day
  86. 86. Dr.Elhawary Management of Medically compromised patients Adrenal Crisis • Clinical features of adrenal crisis: 1. Sever Hypotension 2. Dehydration 3. Circulatory collapse 4. Shock 5. Respiratory collapse N.B. Could lead to death if not treated • Treatment of ADRENAL CRISIS:- 1. Pt in shock position 2. Oxygen 3. Administration of glucocorticoids: 1. Prednisolone IV or IM (4 times > cortisone) 2. Dexamethasone (25 times > cortisone) 4. Vasopressor drugs such as Wyamine sulphate 5. Fluid and electrolytes replacement 6. Hospitalization
  87. 87. Dr.Elhawary Management of Medically compromised patients LIVER DISEASES LIVER CIRRHOSIS HEPATITIS Management of patients with systemic diseases
  88. 88. Dr.Elhawary Management of Medically compromised patients Functions of the liver 1. Exocrine function by production of bile salts 2. Carbohydrates and lipids metabolism (glycogen storage) 3. Detoxification properties 4. Production of bilirubin from the break down of haemoglobin 5. Production of : i. Albumin ii. Clotting factors (prothrombin and fibrinogen) iii. Plasma proteins iv. Urea v. Amino acids
  89. 89. Dr.Elhawary Management of Medically compromised patients Impaired liver functions leads to: 1. Abnormalities in metabolic processes 2. Abnormalities in coagulation 3. Abnormalities in drug metabolism
  90. 90. Dr.Elhawary Management of Medically compromised patients Laboratory investigations used to evaluate hepatic functions : 1. Serum bilrubin when elevated → intrahepatic or obstructivr liver disease 2. Serum alkaline phosphatase when elevated → obstructive liver disease rather than cellular liver disease 3. Serum transaminase levels when elevated → Hepatocellular necrosis (NONSPECIFIC) 4. Serum albumin decreased late during liver diseases 5. Bromsulphalim (BSP) retention (MOST SPECIFIC) 6. Prothrombin time elevated in hepatic disease 7. Antigen antibody markers to differentiate different types of viral hepatitis
  91. 91. Dr.Elhawary Management of Medically compromised patients LIVER DISEASES LIVER CIRRHOSIS Management of patients with systemic diseases
  92. 92. Dr.Elhawary Management of Medically compromised patients • Condition: – Hepatic parenchymal damage with fibrosis and damage of the normal lobular pattern of liver • Etiology: 1. Idiopathic 2. Alcoholism 3. Hepatitis 4. Liver autoimmune disease 5. Hepatotoxins
  93. 93. Dr.Elhawary Management of Medically compromised patients • Clinically: 1. Jaundice 2. Bleeding tendency 3. Portal hypertension 4. Ascites 5. Hypoglycemia 6. Hepatosplenomegaly
  94. 94. Dr.Elhawary Management of Medically compromised patients LIVER DISEASES HEPATITIS Management of patients with systemic diseases
  95. 95. Dr.Elhawary Management of Medically compromised patients • Condition: – Inflammation of the liver cells • Etiology and Types: 1. Primary hepatitis: i. Viral hepatitis ii. Toxic hepatitis iii. Drug induced hepatitis 2. Secondary hepatitis: i. Syphilis ii. TB iii. Infective mononucleosis
  96. 96. Dr.Elhawary Management of Medically compromised patients • Clinically : 1. Anorexia or nausea 2. Fever which gradually subside 3. Enlargement and tenderness of liver 4. Splenomegaly 5. Jaundice 6. Lymphadenopathy • Complications of hepatitis: 1. Degenerative necrosis of liver cells 2. Biochemical abnormalities 3. Liver cirrhosis 4. Hepatocellular carcinoma
  97. 97. Dr.Elhawary Management of Medically compromised patients • Dental management cosideration: 1. Medical Consultation 2. Liver function tests 3. Coagulation screening profile 4. Regulation of the bleeding tendency : i. Blood transfusion prior to surgery if needed ii. Vitamin K injection (10 mg synkavit 1 hour before and after surgery) 5. Stress reduction protocol 6. Prophylactic antibiotics 7. High infection control measures
  98. 98. Dr.Elhawary Management of Medically compromised patients • Dental management cosideration: 8. Avoid hepatotoxic drugs 9. Minimize the use of drugs metabolized in liver 10. LA is safe with small doses and least concentrations 11. Least amount of surgical intervention 12. Local haemostatic measures
  99. 99. Dr.Elhawary Management of Medically compromised patients Drug therapy in liver diseases PreferableTo be avoidedItem ParacetamolMorphine Valium Asprin Analgesics Clindamycin Metronidazole Penicillin Sulphonamides Antibiotics Ester types : Procaine Amide types : mepivicain xylocaine Anesthesia
  100. 100. Dr.Elhawary Management of Medically compromised patients RENAL DISEASES RENAL FAILURE KIDNEY TRANSPLANTATION Management of patients with systemic diseases
  101. 101. Dr.Elhawary Management of Medically compromised patients RENAL DISEASES RENAL FAILURE Management of patients with systemic diseases
  102. 102. Dr.Elhawary Management of Medically compromised patients • Clinically : 1. Nausea and vomiting 2. Loss of weight 3. Pallor 4. Anemia 5. Hypertension 6. Acidosis 7. Congestive heart failure 8. Pulmonary edema 9. Renal osteodystrophy 10.Elevated serum creatinine (0.6→1.2mg / 100ml blood) 11.Elevated BUN (blood urea nitrogen) (8 →23 mg) • Treatment : 1. Artificial blood filtration (dialysis) 2. Kidney transplantation
  103. 103. Dr.Elhawary Management of Medically compromised patients Renal haemodialysis • Dental Management Considerations : 1. Medical Consultation 2. Stress reduction protocol 3. Avoid drugs that are excreted through the kidneys 4. Avoid nephrotoxic drugs 5. Postpone till the same day (not before 4 hours) or better day after dialysis 6. Prophylactic antibiotics to guard against SBE (SHUNT) 7. Least traumatic surgery 8. Least amount of LA 9. High infection control measures
  104. 104. Dr.Elhawary Management of Medically compromised patients Renal Transplant • Dental Management Considerations : 1. Medical Consultation 2. Stress reduction protocol 3. Regulation of the corticosteroids 1. Minimal stress → no change 2. Moderate stress → double the dose 3. severe stress → 100 mg hydrocortisone IV 4. Avoid nephrotoxic drugs 5. Prophylactic antibiotics to minimize bacteremia specially because the patient is under the action of cytotoxic drugs 6. High infection control measures
  105. 105. Dr.Elhawary Management of Medically compromised patients Drug therapy in renal diseases PreferableTo be avoidedItem Paracetamol ibubrufen Aspirin NSAIDs Analgesics Erythromycin Clindamycin Metronidazole Cephalosporens Tetracycline Antibiotics xylocaine ProcaineAnesthesia
  106. 106. Dr.Elhawary Management of Medically compromised patients MISCELLANEOUS PREGNANCY AND LACTATION EPILEPSY HIV OSTEORADIONECROSIS Management of patients with systemic diseases
  107. 107. Dr.Elhawary Management of Medically compromised patients MISCELLANEOUS EPILEPSY Management of patients with systemic diseases
  108. 108. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Medical Consultation 2. Postpone surgery until seizures are well controlled 3. Anticonvulsant Premedication 4. Stress reduction protocol 5. Avoid hypoglycemia 6. Avoid lengthy • In case of seizures 1. Stop the procedure 2. Put patient in supine position 3. Place bite block or tongue blade between teeth
  109. 109. Dr.Elhawary Management of Medically compromised patients MISCELLANEOUS HIV Management of patients with systemic diseases
  110. 110. Dr.Elhawary Management of Medically compromised patients • Acquired immune deficiency syndrome (AIDS) • Condition : 1. Generalized lymphadinopathy 2. Opportunistic infections 3. Malignancies 4. Progressive periodontal disease without local factor 5. Hairy leukoplakia 6. Xerostomia • Dental Management Considerations : 1. Consultation 2. Strict infection control measures
  111. 111. Dr.Elhawary Management of Medically compromised patients MISCELLANEOUS PREGNANCY AND LACTATION Management of patients with systemic diseases
  112. 112. Dr.Elhawary Management of Medically compromised patients • Best time for the dental procedure is the middle or the 2nd trimester due to : 1. Minimal nausea and vomiting 2. Stable fetus 3. Low incidence of obstetrical complications • Emergency treatment can be done at any time • Dental procedures involves potentially harmful elements for pregnant female including: 1. Radiographs 2. Drug administration 3. Pain and stress 4. Supine hypotension in late pregnancy
  113. 113. Dr.Elhawary Management of Medically compromised patients • Dental Management Considerations : 1. Consult the patient’s obstetrician 2. Short appointments 3. Avoid painful stimuli 4. Avoid placing the patient in supine position 5. Avoid radiographs It should be limited and used only after 1st trimester (if necessary use lead apron) 6. LA is more suitable than GA 7. Avoid drugs with teratogenic potential
  114. 114. Dr.Elhawary Management of Medically compromised patients Drugs contraindicated and alternatives in pregnancy PreferableTo be avoidedItem Paracetamol Aspirin NSAIDs Analgesics Penicillin Erythromycin Cephalosporin Tetracycline Aminoglycosides Streptomycin Metronidazole Antibiotics Corticosteroids Others
  115. 115. Dr.Elhawary Management of Medically compromised patients All Preferable medications has to be approved by the patients Gynecologist
  116. 116. Dr.Elhawary Management of Medically compromised patients • Medications to avoid during lactation : 1. Ampicillin 2. Tetracycline 3. Aspirin 4. Steroids 5. Valium 6. Barbiturates • Permissible drugs during lactation : 1. Keflex 2. Erythromycin 3. xylocaine
  117. 117. Dr.Elhawary Management of Medically compromised patients THANK YOU H. ELHAWARY

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