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Medically compromised
        Patient
       Islam Kassem




          ikassem@dr.com
1- Cardiovascular problems
2-Pulmonary problems
3-Renal problems
4-Hepatic disorders
5-Endocrine disorders
6-Hematologic problems
7-neurologic disorders
8-Manaement of pregnant & postpartum patients
                    ikassem@dr.com
1st lecture
1- Cardiovascular problems
2-Pulmonary problems
3-Renal problems
4-Hepatic disorders




                    ikassem@dr.com
2nd Lecture
5-Endocrine disorders.
6-Hematologic problems.
7-neurologic disorders.
8-Manaement of pregnant & postpartum
  patients.




                  ikassem@dr.com
Medically compromised 1
1- Cardiovascular problems

•   Ischemic heart disease
•   Cerebrovascular Accident (stroke)
•   Dysrhythias
•   Infective endocarditis
•   Congestive heart failure




                      ikassem@dr.com
Ischaemic Heart Disease
   Clinical Aspects For
         DENTIST
Coronary Artery Disease




A leading cause of SICKNESS and DEATH
Coronary Heart Disease:
              Myocardial Ischemia
• An imbalance between the supply of oxygen and the
  myocardial demand resulting in myocardial ischaemia.

• Decreased blood supply (and thus oxygen) to the
  myocardium that can result in acute coronary
  syndromes:
   – Angina pectoris ( Stable )
   – Unstable Angina
   – Myocardial infarction
   – Sudden death (due to fatal arrhythmias)
Ischaemic heart disease
                  Aetiology
• Fixed
  – Age, Male, +ve family history
• Modifiable – strong association
  – Dyslipidaemia, smoking, diabetes mellitus, obesity,
    hypertension
• Modifiable - weak association
  – Lack of exercise, high alcohol consumption, type A
    personality, Oral Contraceptive Pills, soft water


   –PRIMARY PREVENTION
          Atherosclerosis
Non-Modifiable Risk Factor:
           SEX
Non-Modifiable Risk Factor:
           AGE
Non-Modifiable Risk Factor:
    FAMILY HISTORY
Modifiable Risk Factor: DIABETES
Modifiable Risk Factor: SMOKING
Modifiable Risk Factor: OBESITY
Modifiable Risk Factor:
   DYSLIPIDEMIA
Ischaemic heart disease
                   Manifestations
• Sudden death
• Acute coronary syndrome ( Myocardial Infarction &
    Unstable Angina )
•   Stable angina pectoris
•   Heart failure
•   Arrhythmia
•   Asymptomatic
Angina Pectoris
• At least 70% occlusion of coronary artery
  resulting in pain.
   – Chest pain
•     - Characteristics: squeezing, bursting, pressing,
       burning or choking
    - Location: substernum
    - Refer pain: L’t shoulder, arm, neck
                 or mandible
    - Associated with exertion, anxiety
    - Relieved by vasodilator (ex. NTG) or
       rest
    - May accompanied by dyspnea, nausea&
      vomiting sensation,
       palpitation
• Usually brought on by physical exertion
• Is self limiting usually stops when exertion is
  ceased
Angina pectoris
• Potential problem related to dental care
   1. Stress and anxiety related to dental visit may precipitate angina
      attack
• Prevention of complication
   1. Detection of patient
   2. Referral of patient for medical evaluation and treatment
   3. Known case with medical treatment for angina
   – Stress reduction protocol
      •   Premedication
      •   Open and honest communication
      •   Morning appointments
      •   Short appointments
      •   Nitrous oxide - oxygen
   – Avoid excessive amounts of epinephrine
1.   Terminate all procedures
2.
3.
     Semi-reclined position
     Sublingual NTG
                                        Angina Pectoris
4.   O2
5.   Check vital signs



Discomfort relieved                        Still discomfort after 3min


6. Assume angina pectoris was present            Give 2nd NTG
7. Slowly taper O2 over 5min
8. Modify dental treatment
                                           Still discomfort after 3min


                                                 Give 3rd NTG


                                           Still discomfort after 3min

                NTG
                0.6mg/tab
10. Assume myocardial infarction in progress
11. On IV line
12. Prepare transport to ER




                                  If highly suspected AMI




        MONA: Morphine, Oxygen, NTG, Aspirin
Myocardial Infarction
• Partial or total occlusion of one or more of the coronary
  arteries due to an atheroma, thrombus or emboli
  resulting in cell death (infarction) of the heart muscle
• When an MI occurs, there is usually involvement of 3 or
  4 occluded coronary vessels
Chest Pain
• Site
  Jaw to navel, retrosternal, left submammary
• Radiation
  Left chest, left arm, jaw….mandible, teeth, palate
• Quality/severity
  tightness, heaviness, compression…clenched fists
• Precipitating/relieving factors
  physical exertion, cold windy weather, emotion
  rest, sublingual nitrates
• Autonomic symptoms
  sweating, pallor, peripheral vasoconstriction, nausea and
  vomiting
Treatment
•   Stop dental treatment
•   Call for help
•   Rest, sit up and reassure patient
•   Oxygen
•   Analgesia (opiate, sublingual nitrate)
•   Aspirin
•   Thrombolysis
•   Primary angioplasty
•   Beta-Blockers
•   ACE inhibitors
•   Prepare for basic life support
•   Transport patient to hospital
Surgical Treatment
• Percutaneous
  Transluminal Coronary
  Angioplasty (PTCA)
  – balloon expansion that
    can provide 90%
    dilitation of vessel
    lumen
  – Stent Placement
• Coronary Artery By-
  Pass Graft (CABG)
Dental Considerations for IHD
• Common Situations:
   – Orthostatic Hypotension due to use of anti-hypertensives (beta
     blockers, nitroglycerin…)
       • Raise chair slowly
       • Allow patient to take his/her time
       • Assist patient in standing
   – Post-Op Bleeding:
       • When patients on Plavix or Aspirin, expect increased bleeding because of
         decreased platelet aggregation
• Emergent Situations:
   – Possible MI:
       • Remember that pain in the jaw may be referred pain from the
         myocardium  assess the situation, have good patient history, follow
         ABC’s
   – Angina:
       • In situations of angina pectoris, all operatories should have nitroglycerin
         to be placed sublingually
RISK FOR DENTAL PROCEDURE
• Major Risk for Perioperative Procedures:
   – Unstable Angina (getting worse)
   – Recent MI
• Intermediate Risk for Perioperative Procedures:
   – Stable Angina
   – History of MI
• Most dental procedures, even surgical procedures fall
  within the risk of less than 1%
• Some procedures fall within an intermediate risk of less
  than 5%
• Highest risk procedures  those done under general
  anesthesia
Post MI: When to Treat
• Why delay treatment?
   – Remember that with an MI there is damage to the heart, be it
     severe or minimal that may effect the patient’s daily life
• MI within 1 month  Major Cardiac Risk
• MI within longer then 1 month:
   – Stable  routine dental care ok
   – Unstable  treat as Major Cardiac Risk
• Older studies suggest high re-infarction rates when surgery performed
  within 3 months, 3-6 months… however, this was abdominal and
  thoracic surgery under general anesthesia
• New research suggests delaying elective tx for 1 month is advisable.
  Emergent care should be done with local anesthetic without
  epinephrine and monitoring of vital signs
• When in doubt:
                – CONSULT THE CARDIOLOGIST
Dental Management:
                Stable Angina/Post-MI >4-6 weeks
•   Minimize time in waiting room
•   Short, morning appointments
•   Preop, intra-op, and post-op vital signs
•   Pre-medication as needed
    – anxiolytic (triazolam; oxazepam); night before and 1 hour before
    – Have nitroglycerin available – may consider using prophylacticaly
• Use pulse oximeter to assure good breathing and oxygenation
• Oxygen intraoperatively (if needed)
• Excellent local anesthesia - use epinephrine, if needed, in limited
  amount (max 0.04mg) or levonordefrin (max. 0.20mg)
• Avoid epinephrine in retraction cord
Dental Management:
         Unstable Angina or MI < 3 months
• Avoid elective care
• For urgent care: be as conservative as possible;
  do only what must be done (e.g. infection
  control, pain management)
• Consultation with physician to help manage
• Consider treating in outpatient hospital facility or
  refer to hospital dentistry
• ECG, pulse oximetry, IV line
• Use vasoconstrictors cautiously if needed
Warning Signs and Symptoms of Heart
                    attack
1)  Pressure, fullness or a squeezing pain in the center of chest
    that lasts for more than a few minutes.
2) Pain extending beyond the chest to the shoulder, arm, back or
    even your teeth and jaw.
3) Increasing episodes of chest pain
4) Prolonged pain in the upper abdomen
5) Shortness of breath- may occur with or without chest
    discomfort
6) Sweating
7) Impending sense of doom
8) Lightheadedness
9) Fainting
10) Nausea and vomiting
Conclusion:
• When treating patients with Ischemic Heart Disease
  or recent MI…
   – Use caution and common sense
   – When in doubt:
      • CONSULT THE CARDIOLOGIST
Dental Management
             of
Patients with Heart Failure
Sequelae of Heart Failure
• Right Heart              • Left Heart
  Failure                    Failure
  – Systemic                  – Pulmonary
    venous                      edema
    congestion                  (Dyspnea)
    (distended
    neck veins,
    enlarged liver,
    peripheral
    edema,
    ascites)
Symptoms of Heart Failure

Compensated (Asymptomatic)

Uncompensated (Symptomatic)
• Fatigue
• Dyspnea
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Ankle Edema
• Weight Gain

Note: patients with a very low EF may have no symptoms
Functional Classification of Heart Failure

• Class I: No limitation of physical activity. No
  dyspnea, fatigue, or palpitations with ordinary
  physical activity
• Class II: Slight limitation of physical activity.
  Fatigue, palpitations and dyspnea with ordinary
  physical activity but comfortable at rest.
• Class III: Marked limitation of activity. Less than
  ordinary physical activity results in symptoms but
  comfortable at rest.
• Class IV: Symptoms present at rest and any physical
  activity exacerbates the symptoms
Dental Management Considerations
               (Heart Failure)
• For undiagnosed pt with symptoms of HF: avoid
  elective care; refer to physician
• For patients with diagnosed HF:
  – Class I (asymptomatic): routine care
  – Class II (mild symptoms with exertion): elective care
    OK and recommend consultation with physician
  – Class III or IV (symptoms with minimal activity or at
    rest): avoid elective care; if treatment necessary,
    manage in consultation with physician; consider
    referral to a special patient care setting; avoid use of
    vasoconstrictors
ikassem@dr.com
ikassem@dr.com
ikassem@dr.com
ikassem@dr.com
ikassem@dr.com
2-Pulmonary problems

• Asthma
• Chronic obstructive pulmonary disease




                    ikassem@dr.com
Asthma
• Characterized by reversible airway obstruction
  and associated with a reduction in expiratory
  airflow
  – May be precipitated by allergens, pollution,
    exercise, stress, or upper respiratory tract
    infection
  – In status asthmaticus, patients have persistent life-
    threatening bronchospasm despite drug therapy
  – Signs of asthma include shortness of breath and
    wheezing
Chronic Obstructive Pulmonary
              Disease
• Irreversible airway obstruction; occurs with
  either chronic bronchitis or emphysema
  – Chronic bronchitis is a result of chronic
    inflammation of the airways and excessive
    sputum production
  – Emphysema is characterized by alveolar
    destruction with airspace enlargement and
    airway collapse
Corticosteroids
• Typical side effects seen with corticosteroid
  therapy do not occur with topical aerosol
  administration
  – Patients have a significant improvement in
    pulmonary function with a decrease in wheezing,
    tightness, and cough
  – Reduce inflammation, secretions and swelling in
    the lungs after an asthma attack
• Prolonged inhalation may cause candidiasis
Dental Implications of the Respiratory
                Drugs
• About 10% of the population has some form
  of pulmonary disease
  – With severe COPD, a person can develop
    pulmonary hypertension, increasing the risk for
    cardiac arrhythmias
  – Stress should be minimized and adrenal
    supplementation instituted if the patients are
    taking certain doses of steroids and the procedure
    is likely to produce severe stress
ikassem@dr.com
3-Renal problems

• Renal faliure
• Renal transplant & transplant of other organ
• Hypertension




                     ikassem@dr.com
Anatomy
•   2 Kidneys
•   2 Ureters
•   Bladder
•   Urethra
Medically compromised 1
Kidney Function
• Detoxify blood
• Increase calcium absorption
  – calcitriol
• Stimulate RBC production
  – erythropoietin
• Regulate blood pressure and electrolyte
  balance
  – renin
Medically compromised 1
Medically compromised 1
Medically compromised 1
Symptoms of ARF
•   Decrease urine output (70%)
•   Edema, esp. lower extremity
•   Mental changes
•   Heart failure
•   Nausea, vomiting
•   Pruritus
•   Anemia
•   Tachypenic
•   Cool, pale, moist skin
Medically compromised 1
Chronic Renal Failure Causes
•   Diabetic Nephropathy
•   Hypertension
•   Glomerulonephritis
•   HIV nephropathy
•   Reflux nephropathy in children
•   Polycystic kidney disease
•   Kidney infections & obstructions
Dialysis
• ½ of patients with CRF eventually require
  dialysis
• Diffuse harmful waste out of body
• Control BP
• Keep safe level of chemicals in body
• 2 types
  – Hemodialysis
  – Peritoneal dialysis
Hemodialysis
• 3-4 times a week
• Takes 2-4 hours
• Machine filters
 blood and
 returns it to
 body
ikassem@dr.com
ikassem@dr.com
4-Hepatic disorders




       ikassem@dr.com
Hepatic Disorders

 Hepatic Insufficiency
Hepatic Disorders
Management of Patient with Hepatic Insufficiency
1. Attempt to learn the cause of the liver problem; if the
   cause is hepatitis B, take usual precautions.
2. Avoid drugs requiring hepatic metabolism or excretion; if
   their use is necessary, modify the dose.
3. Screen patients w i t h severe liver disease for bleeding
   disorders with platelet count, prothrombin time, partial
   thromboplastin time, and Ivy's bleeding time.
4. Attempt to avoid situations in which the patient might
   swallow large amounts of blood.
Study source?




    ikassem@dr.com
Contemprary Oral &
  maxillofacial surgery
Page 10-20




                          ikassem@dr.com
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Medically compromised 1

  • 1. Medically compromised Patient Islam Kassem ikassem@dr.com
  • 2. 1- Cardiovascular problems 2-Pulmonary problems 3-Renal problems 4-Hepatic disorders 5-Endocrine disorders 6-Hematologic problems 7-neurologic disorders 8-Manaement of pregnant & postpartum patients ikassem@dr.com
  • 3. 1st lecture 1- Cardiovascular problems 2-Pulmonary problems 3-Renal problems 4-Hepatic disorders ikassem@dr.com
  • 4. 2nd Lecture 5-Endocrine disorders. 6-Hematologic problems. 7-neurologic disorders. 8-Manaement of pregnant & postpartum patients. ikassem@dr.com
  • 6. 1- Cardiovascular problems • Ischemic heart disease • Cerebrovascular Accident (stroke) • Dysrhythias • Infective endocarditis • Congestive heart failure ikassem@dr.com
  • 7. Ischaemic Heart Disease Clinical Aspects For DENTIST
  • 8. Coronary Artery Disease A leading cause of SICKNESS and DEATH
  • 9. Coronary Heart Disease: Myocardial Ischemia • An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia. • Decreased blood supply (and thus oxygen) to the myocardium that can result in acute coronary syndromes: – Angina pectoris ( Stable ) – Unstable Angina – Myocardial infarction – Sudden death (due to fatal arrhythmias)
  • 10. Ischaemic heart disease Aetiology • Fixed – Age, Male, +ve family history • Modifiable – strong association – Dyslipidaemia, smoking, diabetes mellitus, obesity, hypertension • Modifiable - weak association – Lack of exercise, high alcohol consumption, type A personality, Oral Contraceptive Pills, soft water –PRIMARY PREVENTION Atherosclerosis
  • 13. Non-Modifiable Risk Factor: FAMILY HISTORY
  • 17. Modifiable Risk Factor: DYSLIPIDEMIA
  • 18. Ischaemic heart disease Manifestations • Sudden death • Acute coronary syndrome ( Myocardial Infarction & Unstable Angina ) • Stable angina pectoris • Heart failure • Arrhythmia • Asymptomatic
  • 19. Angina Pectoris • At least 70% occlusion of coronary artery resulting in pain. – Chest pain • - Characteristics: squeezing, bursting, pressing, burning or choking - Location: substernum - Refer pain: L’t shoulder, arm, neck or mandible - Associated with exertion, anxiety - Relieved by vasodilator (ex. NTG) or rest - May accompanied by dyspnea, nausea& vomiting sensation, palpitation • Usually brought on by physical exertion • Is self limiting usually stops when exertion is ceased
  • 20. Angina pectoris • Potential problem related to dental care 1. Stress and anxiety related to dental visit may precipitate angina attack • Prevention of complication 1. Detection of patient 2. Referral of patient for medical evaluation and treatment 3. Known case with medical treatment for angina – Stress reduction protocol • Premedication • Open and honest communication • Morning appointments • Short appointments • Nitrous oxide - oxygen – Avoid excessive amounts of epinephrine
  • 21. 1. Terminate all procedures 2. 3. Semi-reclined position Sublingual NTG Angina Pectoris 4. O2 5. Check vital signs Discomfort relieved Still discomfort after 3min 6. Assume angina pectoris was present Give 2nd NTG 7. Slowly taper O2 over 5min 8. Modify dental treatment Still discomfort after 3min Give 3rd NTG Still discomfort after 3min NTG 0.6mg/tab
  • 22. 10. Assume myocardial infarction in progress 11. On IV line 12. Prepare transport to ER If highly suspected AMI MONA: Morphine, Oxygen, NTG, Aspirin
  • 23. Myocardial Infarction • Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle • When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels
  • 24. Chest Pain • Site Jaw to navel, retrosternal, left submammary • Radiation Left chest, left arm, jaw….mandible, teeth, palate • Quality/severity tightness, heaviness, compression…clenched fists • Precipitating/relieving factors physical exertion, cold windy weather, emotion rest, sublingual nitrates • Autonomic symptoms sweating, pallor, peripheral vasoconstriction, nausea and vomiting
  • 25. Treatment • Stop dental treatment • Call for help • Rest, sit up and reassure patient • Oxygen • Analgesia (opiate, sublingual nitrate) • Aspirin • Thrombolysis • Primary angioplasty • Beta-Blockers • ACE inhibitors • Prepare for basic life support • Transport patient to hospital
  • 26. Surgical Treatment • Percutaneous Transluminal Coronary Angioplasty (PTCA) – balloon expansion that can provide 90% dilitation of vessel lumen – Stent Placement • Coronary Artery By- Pass Graft (CABG)
  • 27. Dental Considerations for IHD • Common Situations: – Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…) • Raise chair slowly • Allow patient to take his/her time • Assist patient in standing – Post-Op Bleeding: • When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation • Emergent Situations: – Possible MI: • Remember that pain in the jaw may be referred pain from the myocardium  assess the situation, have good patient history, follow ABC’s – Angina: • In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually
  • 28. RISK FOR DENTAL PROCEDURE • Major Risk for Perioperative Procedures: – Unstable Angina (getting worse) – Recent MI • Intermediate Risk for Perioperative Procedures: – Stable Angina – History of MI • Most dental procedures, even surgical procedures fall within the risk of less than 1% • Some procedures fall within an intermediate risk of less than 5% • Highest risk procedures  those done under general anesthesia
  • 29. Post MI: When to Treat • Why delay treatment? – Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patient’s daily life • MI within 1 month  Major Cardiac Risk • MI within longer then 1 month: – Stable  routine dental care ok – Unstable  treat as Major Cardiac Risk • Older studies suggest high re-infarction rates when surgery performed within 3 months, 3-6 months… however, this was abdominal and thoracic surgery under general anesthesia • New research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signs • When in doubt: – CONSULT THE CARDIOLOGIST
  • 30. Dental Management: Stable Angina/Post-MI >4-6 weeks • Minimize time in waiting room • Short, morning appointments • Preop, intra-op, and post-op vital signs • Pre-medication as needed – anxiolytic (triazolam; oxazepam); night before and 1 hour before – Have nitroglycerin available – may consider using prophylacticaly • Use pulse oximeter to assure good breathing and oxygenation • Oxygen intraoperatively (if needed) • Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg) • Avoid epinephrine in retraction cord
  • 31. Dental Management: Unstable Angina or MI < 3 months • Avoid elective care • For urgent care: be as conservative as possible; do only what must be done (e.g. infection control, pain management) • Consultation with physician to help manage • Consider treating in outpatient hospital facility or refer to hospital dentistry • ECG, pulse oximetry, IV line • Use vasoconstrictors cautiously if needed
  • 32. Warning Signs and Symptoms of Heart attack 1) Pressure, fullness or a squeezing pain in the center of chest that lasts for more than a few minutes. 2) Pain extending beyond the chest to the shoulder, arm, back or even your teeth and jaw. 3) Increasing episodes of chest pain 4) Prolonged pain in the upper abdomen 5) Shortness of breath- may occur with or without chest discomfort 6) Sweating 7) Impending sense of doom 8) Lightheadedness 9) Fainting 10) Nausea and vomiting
  • 33. Conclusion: • When treating patients with Ischemic Heart Disease or recent MI… – Use caution and common sense – When in doubt: • CONSULT THE CARDIOLOGIST
  • 34. Dental Management of Patients with Heart Failure
  • 35. Sequelae of Heart Failure • Right Heart • Left Heart Failure Failure – Systemic – Pulmonary venous edema congestion (Dyspnea) (distended neck veins, enlarged liver, peripheral edema, ascites)
  • 36. Symptoms of Heart Failure Compensated (Asymptomatic) Uncompensated (Symptomatic) • Fatigue • Dyspnea • Orthopnea • Paroxysmal Nocturnal Dyspnea • Ankle Edema • Weight Gain Note: patients with a very low EF may have no symptoms
  • 37. Functional Classification of Heart Failure • Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity • Class II: Slight limitation of physical activity. Fatigue, palpitations and dyspnea with ordinary physical activity but comfortable at rest. • Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms but comfortable at rest. • Class IV: Symptoms present at rest and any physical activity exacerbates the symptoms
  • 38. Dental Management Considerations (Heart Failure) • For undiagnosed pt with symptoms of HF: avoid elective care; refer to physician • For patients with diagnosed HF: – Class I (asymptomatic): routine care – Class II (mild symptoms with exertion): elective care OK and recommend consultation with physician – Class III or IV (symptoms with minimal activity or at rest): avoid elective care; if treatment necessary, manage in consultation with physician; consider referral to a special patient care setting; avoid use of vasoconstrictors
  • 44. 2-Pulmonary problems • Asthma • Chronic obstructive pulmonary disease ikassem@dr.com
  • 45. Asthma • Characterized by reversible airway obstruction and associated with a reduction in expiratory airflow – May be precipitated by allergens, pollution, exercise, stress, or upper respiratory tract infection – In status asthmaticus, patients have persistent life- threatening bronchospasm despite drug therapy – Signs of asthma include shortness of breath and wheezing
  • 46. Chronic Obstructive Pulmonary Disease • Irreversible airway obstruction; occurs with either chronic bronchitis or emphysema – Chronic bronchitis is a result of chronic inflammation of the airways and excessive sputum production – Emphysema is characterized by alveolar destruction with airspace enlargement and airway collapse
  • 47. Corticosteroids • Typical side effects seen with corticosteroid therapy do not occur with topical aerosol administration – Patients have a significant improvement in pulmonary function with a decrease in wheezing, tightness, and cough – Reduce inflammation, secretions and swelling in the lungs after an asthma attack • Prolonged inhalation may cause candidiasis
  • 48. Dental Implications of the Respiratory Drugs • About 10% of the population has some form of pulmonary disease – With severe COPD, a person can develop pulmonary hypertension, increasing the risk for cardiac arrhythmias – Stress should be minimized and adrenal supplementation instituted if the patients are taking certain doses of steroids and the procedure is likely to produce severe stress
  • 50. 3-Renal problems • Renal faliure • Renal transplant & transplant of other organ • Hypertension ikassem@dr.com
  • 51. Anatomy • 2 Kidneys • 2 Ureters • Bladder • Urethra
  • 53. Kidney Function • Detoxify blood • Increase calcium absorption – calcitriol • Stimulate RBC production – erythropoietin • Regulate blood pressure and electrolyte balance – renin
  • 57. Symptoms of ARF • Decrease urine output (70%) • Edema, esp. lower extremity • Mental changes • Heart failure • Nausea, vomiting • Pruritus • Anemia • Tachypenic • Cool, pale, moist skin
  • 59. Chronic Renal Failure Causes • Diabetic Nephropathy • Hypertension • Glomerulonephritis • HIV nephropathy • Reflux nephropathy in children • Polycystic kidney disease • Kidney infections & obstructions
  • 60. Dialysis • ½ of patients with CRF eventually require dialysis • Diffuse harmful waste out of body • Control BP • Keep safe level of chemicals in body • 2 types – Hemodialysis – Peritoneal dialysis
  • 61. Hemodialysis • 3-4 times a week • Takes 2-4 hours • Machine filters blood and returns it to body
  • 64. 4-Hepatic disorders ikassem@dr.com
  • 65. Hepatic Disorders Hepatic Insufficiency
  • 66. Hepatic Disorders Management of Patient with Hepatic Insufficiency 1. Attempt to learn the cause of the liver problem; if the cause is hepatitis B, take usual precautions. 2. Avoid drugs requiring hepatic metabolism or excretion; if their use is necessary, modify the dose. 3. Screen patients w i t h severe liver disease for bleeding disorders with platelet count, prothrombin time, partial thromboplastin time, and Ivy's bleeding time. 4. Attempt to avoid situations in which the patient might swallow large amounts of blood.
  • 67. Study source? ikassem@dr.com
  • 68. Contemprary Oral & maxillofacial surgery Page 10-20 ikassem@dr.com
  • 69. • You can get it form • http://www.slideshare.net/islamkassem