Management of Medically Compromised Patients in Dental Clinic PDF

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This document provides an overview of managing medically compromised patients in a dental clinic setting. It touches on various aspects like initial assessment, pre-surgical evaluations, and a general approach to patient management.

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Management of Medically compromised Patients in dental clinic By: (MSc, PhD) Lecturer of OMFS Faculty of Dentistry Alexandria University General concept Are we treating A patient Vs a tooth?? Medically compromised Patients...

Management of Medically compromised Patients in dental clinic By: (MSc, PhD) Lecturer of OMFS Faculty of Dentistry Alexandria University General concept Are we treating A patient Vs a tooth?? Medically compromised Patients Pre-surgical evaluation: General physical condition Medical consultation Drug senstivity / interaction Premedication Choice of anaesthesia Need/quantity of vasoconstrictor Technique employed Operative time Postoperative considerations American Society of Anesthesiologists” ASA” Classification It is a grading system to determine the health of a person before a surgical procedure that requires anesthesia.. ASA Classification ASA I: A normal, healthy patient ASA II: A patient with mild systemic disease or significant health risk factor ASA III: A patient with severe systemic disease that is not incapacitating ASA IV: A patient with severe systemic disease that is a constant threat to life ASA V: A moribund patient who is not expected to survive without the operation ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes Threats faces Medically compromised patient Stress Signs of Acute Anxiety ▪ ▪ ▪ ▪ ▪ ▪ ▪ First Consultation ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Communication Stress Reduction in Dentistry Before Appointment During Appointment After Surgical procedure Stress Reduction in Dentistry Pre-Surgical During- Post-Surgical Procedure Surgical Procedure Procedure Medical History Iatro-sedation Written Anxiety Reduction Relaxation Tech. Instructions Music, Aroma. Analgesics Proper Rest / Diet Hypnosis Follow-up Transportation Acupuncture Telephone Medication Local Anaesthetic Referral, if needed Short Morning Topical Appointment Definition Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar). General Manifestations of DM Oral Manifestations of DM Dry mouth (xerostomia), Tooth decay (including root caries), Gingivitis, periodontal disease, oral candidiasis, burning mouth , Altered taste, Geographic tongue, coated and fissured tongue, oral lichen planus (OLP), recurrent aphthous stomatitis, increased tendency to infections, and defective wound healing & periapical lesions. Fasting blood glucose concentration (for 8 hours) Normal 70 -100 mg/dL At Risk 100 to 125 mg/dL (changes in lifestyle and monitoring glycemia are recommended). Diabetic : 126 mg/dL or Higher on two separate tests. Fasting blood glucose concentration (for 8 hours) Hemoglobin A1C (HbA1c) test GLUCOSE (GL) enters bloodstream Attaches to hemoglobin (Hb) in RBCS Higher blood sugar levels have more GL attached to HB. A1C test measures the percentage of RBCS that have sugar-coated hemoglobin Over the past 3 months (life span of RBCS). Hemoglobin A1C (HbA1c) test Normal Below 5.7% Prediabetes 5.7% to 6.4% Diabetes 6.5% or above Random Blood Sugar Test This measures blood sugar level at the time tested. This test can be done at any time and don’t need to fast first. A blood sugar level of 200 mg/dL or higher indicates diabetes. Management Problems encountered of Diabetic Parient during &after surgical procedure: Acute Oral Infection Non-insulin-controlled patients may require insulin; consultation with physician required. Insulin-controlled patients usually require increased dosage of insulin;consultation with physician required Culture taken from the infected area for antibiotic sensitivity testing Antibiotic therapy initiated. Warm intraoral rinses. Incision and drainage (if abscess present this is the first line of trerment). Pulpotomy, pulpectomy, extractions. Bleeding Local hemostatic measures: ❑Pressure packs using gauze ❑Local anaesthetic solution with vasoconstrictor injected on a gauze and placed over source of bleeding. ❑Gel foam (resorbs 4-6weeks without inducing excessive scar tissue) and bone wax(non- resosrbable). Hemostatic effect is based mechanically obstructing vessels. ❑Sutures if there is laceration of soft tissue. Hypoglycemic coma Hyperglycemic coma Leads to life threatening consequences usually doesn't cause symptoms until blood sugar levels are high — above 180 to 200 mg/dL. It occurs when concentration of blood glucose drops below 60 mg/dI Signs and symptoms Early signs and symptoms Confusion Frequent urination Restlessness Increased thirst Tremors Blurred vision Sweating Feeling weak or unusually tired Tachycardia. Hypoglycemic coma Hyperglycemic coma Establishing airway,breathing, and circulation. Later signs and symptoms Place the patient in the supine position If hyperglycemia isn't treated, it can cause toxic acids, called ketones, to Conscious give sweetie juice or candy or sugar build up in the blood and urine. This condition is called ketoacidosis. Unconscious patient 50% dextrose Symptoms include: intravenously or Glucagon intramuscularly Fruity-smelling breath until consciousness is regained. Dry mouth Abdominal pain Turn on the fans, conditioner. Nausea and vomiting Should be resolved in 10 to 15 min, observation Shortness of breath 30 to 60 min after the recovery Confusion Check the glucose by the glucometer before Loss of consciousness patient leave. Managed by :Insulin administration Adrenal insufficiency Modulate vascular instability & reduce hypotension induced by stress Otherwise, if not secreted the patient would be subjected to adrenal insufficiency syndrome and with sudden drop of blood pressure and heart rate leading to shock. Modulate vascular instability & reduce hypotension induced by stress Prolonged corticosteroid therapy and Addison’s disease (adrenal glands make too little cortisols) lead to reduction of ACTH production leading to negative feedback control of cortisol and cortisone resulting in adrenal cortex atrophy. So if the patient faces a stressful condition such as dental treatment, adrenaline will not respond properly by hormone release and a risk of Steroid crisis will develop which is manifested as : Severe hypotension Dehydration Hyperpyrexia Nausea and vomiting Weakness and headache Managed by : ✓ Patient laid flat with oxygen ✓ Immediate (IV or IM injection of 100 ml corticosteroid) ✓ Medical Assistance Prevention: Patients on systemic corticosteroids should be covered with an extra dose of steroids on the day of the surgery (Normal dose is doubled). During stress Corticotropin-releasing hormone (CRH) is released from the hypothalamus. CRH stimulates the anterior pituitary to release Adrenocorticotropic hormone (ACTH). ACTH acts on the adrenal cortex to release cortisol and androgens. The increase in cortisol provides a negative feedback system to decrease the amount of CRH released from the hypothalamus. The adrenal cortex secretes glucocorticoids from the zona fasciculata and androgens from the zona reticularis. The secretion of glucocorticoids provides a negative feedback loop for inhibiting the release of CRH and ACTH from the hypothalamus and anterior pituitary, respectively. Stress stimulates the release of ACTH. Thyroid gland releases Thyroid hormones T3 & T4 Hyperthyroidism Results from excessive production of thyroid hormones Precautions to avoid toxic thyroid crisis Symptoms of Restless, disorientation, semi- the thyroid consciousness crisis Rapid thready pulse Hyperthermia which may reach a leathel body temperature Cardiac arrhythmia ( may lead to cardiac failure). Management of thyroid crisis Management should support patient’s life. Urgent call of medical assistance Establishment of patient airway Adminstration of oxygen IV corticosteroids (Hydrocortisone 100 mg IV) Iv fluid to correct dehydration Cold packs to decrease body temperature. Hypothyroidism Patients who have hypothyroidism are sensitive to central nervous system depressants and barbiturates so these medications should be used sparingly. Hemostasis - Patients with long standing hypothyroidism may have increased subcutaneous mucopolysaccharides due to decrease in the degradation of these substances. The presence of excess subcutaneous mucopolysaccharides may decrease the ability of small blood vessels to constrict when cut and may result in increased bleeding Hypertension Increase in blood pressure more than normal values Normal: 120/80 mmHg. Pre hypertensive: ✓ Systolic : 121-139 mmHg ✓ Diastolic: 81-89 mmHg Hypertension: 140/90 mmHg or Higher. So watchout for stress Hypertension Increased Diastolic blood pressure is more Alarming than increased systolic blood pressure (usually compensatory), while diastolic blood pressure means heart is subjected to excess pressure and load even at rest (too much effort). Hypertension o Raised BP resulting : from increased peripheral arteriolar resistance ( narrowing of the vessels). Idiopathic (essential) hypertension (80-90%) Secondary hypertension (10-20 %) 1. Renal disease 2. Endocrine disease ;Cushing’s syndrome and phaeochromocytoma. 3. Cerebral disease; or tumors. 4. Coarctation of aorta (hypertension in upper half of body only) (part of the aorta is narrower than usual). Hypertension Blurry or double vision. Fatigue. Headache. Symptoms (late stage): Heart palpitations. Nosebleeds. (180/110 mmHg) Shortness of breath. Nausea and/or vomiting. fainting. Hypertension Dental Management Night before Surgery : In anxious patients give anxyiolytics, Example : Diazepam tablets 5-10 mg) the night before the surgery and again 1-2 hours before surgery. Or Midazolame IV (0.7mg/kg body weight) (more potent and has a shorter duration of action than diazepam). Early appointement. Stress-reduction protocol. Local Anesthesia: ✓Pre-hypertensive or controlled patient give L.A with vasoconstrictor Hypertension Dental Management Mild to Moderate Hypertension (Systolic >140 mm Hg; Diastolic >90 mm Hg): Recommended that the patient seek the primary care physician’s guidance for medical therapy of hypertension. It is not necessary to defer needed dental care. Monitor the patient’s blood pressure at each visit and whenever administration of epinephrine-containing local anesthetic. You can inject Up to 4 L.A carpules containing Vasoconstrictor. Hypertension Dental Management Mild to Moderate Hypertension (Systolic >140 mm Hg; Diastolic >90 mm Hg) Use an anxiety-reduction protocol. Avoid rapid posture changes in patients taking drugs that cause vasodilation (ex: beta blockers). Avoid administration of sodium-containing intravenous solutions. Hypertension Dental Management Severe Hypertension (Systolic >200 mm Hg; Diastolic >110 mm Hg) or patients with symptoms ✓Emergency treatment Only. ✓Medical consultation is required. ✓L.A with vasoconstrictor up to 0.04 epinephrine (2 carpules) ✓Postoperatively no need for antibiotics nor anti-inflammatory , If prescribing Non- steroidal anti-inflammatory drugs (NSAID’s) not more than 5 days so to avoid interaction with anti-hypertensive drugs. Hypertension Blurry or double vision. Fatigue. Headache. Symptoms (late stage): Heart palpitations. Nosebleeds. (180/110 mmHg) Shortness of breath. Nausea and/or vomiting. fainting. Cardiac Disorders Cardiac Disorders Ischemic Heart Disease ✓Angina Pectoris ✓Myocardial infarction (don’t operate till at least 6 months of last attack). ✓Heart Failure Valvular Heart Disease: ✓Rheumatic HD ✓Valvular Prosthesis Cardiac Disorders Ischemic Heart Disease Disease of the coronary arteries due to narrowing of one or two of the main branches. This lead to imbalance between the blood supply to the myocardium and its metabolic needs lead to myocardial ischemia If Ischemia is mild and of short duration Angina pectoris results. If severe and for longer time Myocardial infarction results. Angina Pectoris Angina pectoris is the name given to paroxysms of severe ischemic chest pain which are typically precipitated by effort and relieved by rest. Or It is a clinical syndrome of episodic chest discomfort resulting from transient myocardial ischemia, produced by exertion, emotion or stress and which is relieved by rest or nitrates. Angina occurs when the oxygen Angina Pectoris demands of the myocardium exceed Pathophysiology that which is provided to it by the coronary arteries. The pain is due to ischemia and usually persists till the oxygen supply is restored or the demand for oxygen reduces. There is no permanent damage to the myocardium Physical exertion Angina Pectoris Stress Precipitating Factors Heavy meals Cold exposure Smoking Emotional disturbances Vivid dreams (nocturnal angina) Lying flat (angina decubitus) Some patients feel pain during initial period of walking but later on, it does not come up despite greater effort called ‘start – up angina’. Angina occurring on lying flat or in recumbent position is called ‘angina decubitus’, seen in patients with heart failure (because gravity redistributes fluids in the body. This redistribution makes the heart work harder). Angina at night is called ‘nocturnal angina’. It is usually precipitated by vivid dreams. Types of Angina Stable Angina Angina is termed stable if it occurs only on exertion and is relieved by rest, within 10 minutes and there have been no changes in the frequency or duration of symptoms or precipitating factors within the previous 60 days. Provoked by 4 “Es” : Exercise , Eating, Emotions, Exposure to cold. Types of Angina Unstable Angina Activated even if patient at rest. Is that in which there are changes in pattern, frequency or duration of precipitating factors, sudden onset angina is considered to be unstable. Clinical Features More common in males. Age 40 to 60 years. Tightness, heaviness, compression or constriction of the chest may be complained but the pain is rarely of the unbearable, crushing and persistent nature of myocardial. Clinical Features The typical site is behind the sternum radiating to the left particularly, sometimes to the left upper arm and occasionally to left mandible, teeth, tongue or palate. Patients who develop angina often have no history of heart disease. The mortality rate in angina is about 4 percent per year. Potential Problems Related to Dental Care Stress and anxiety related to dental visit could precipitate an anginal attack, MI, or sudden death in the office. Dental Management Consult the patient’s physician. Use an anxiety-reduction protocol. Consider Nitrous oxide sedation. Give Nitroglycerin tablets before starting and keep it in hand. Ensure profound local anesthesia before starting surgery. Dental Management Consider possible limitation of amount of epinephrine used (0.04 mg maximum). Monitor vital signs closely. Maintain verbal contact with patient throughout the procedure to monitor status. Stable Angina (low – intermediate risk) : Elective dental care may be provided with the following management considerations : ✓ Short morning appointments, stress reduction measures. ✓ Comfortable chair position. ✓ Pretreatment vital signs, nitroglycerin available ✓ Limit quantity of vasoconstrictor, avoid epinephrine in retraction cords. ✓ Ensure excellent intraoperative and postoperative pain control. Stable Angina (low – intermediate risk) : Elective dental care may be provided with the following management considerations : ✓If patient taking aspirin, excess bleeding is usually controllable by local hemostatic measures only. Prevention of Problem Unstable Angina (Major risk) : Elective dental care should be postponed if possible; if care is necessary, it should be provided in consultation with physician. Management may include establishment of IV line, sedation, electrocardiogram, pulse oximeter, cautious use of vasoconstrictor and prophylactic nitroglycerin. Treatment Plan Modifications Unstable Angina Dental treatment should be limited to that which is absolutely necessary, such as for infection or pain. Stable Angina Any desired dental treatment may be provided taking into consideration appropriate management considerations. Angina in the Dental Office ❖If a patient experiences chest pain, dental treatment must be stopped, the chair is put in a sitting or semi reclining position. ❖If there is history of angina, the patient should be given glyceryl trinitrate 0.5 mg. sublingually and oxygen. ❖Vital signs should be monitored. Angina in the Dental Office ❖The pain should be relieved in 2-3 minutes, the patient should then rest and be accompanied home. ❖If chest pain is not relieved within about 5 minutes, myocardial infarction is the probable cause and medical help should be commenced. Heart failure ❑It is not a disease but an effect of many disorders ❑Ischemic heart disease, hypertension and valve disease are the common causes. Heart failure Right side HF Left side HF Dental Aspects of Heart Failure Elective surgery under GA is contraindicated until CHF is under control. In controlled patient, treatment under LA can be safely be carried out providing that underlying cause is considered. Placing the patient in supine position may increase dyspnea and should be avoided. Rheumatic Fever Rheumatic fever follows a group A Streptococcal infection of upper respiratory tract. Occur at all stages but usually between 5-15 years. Environmental factors eg: overcrowding promote transmission of strept. Infections. Rheumatic Fever Higher among lower socio-economic groups. Clinical onset is acute occurs 2-3 weeks after a sore throat. Joints pain is common. Carditis is most serious manifestation (40-50% of cases) Dental Care Most important aspect in planning care is prevention of dental disease Aggressive preventive regimen is commenced Dietary counselling Fluoride therapy Fissure sealants Oral hygiene instructions Regular monitoring both clinically & radiographically Reinforcement of preventive advice Active dental disease treated before cardiac surgery Treatment Planning If invasive procedures are required, then antibiotic prophylaxis is necessary Antibiotic prophylaxis will influence treatment planning Ideally treatment for children is provided during short appointments so that co-operation is maximized However, balance should be struck against the stress of longer appointments Treatment Planning If multiple appointments with prophylaxis is needed, then 2-4 weeks should be allowed between appointments to allow Penicillin-resistant organisms to disappear. Treatment Planning No child with symptomatic cardiac problems should have routine dental treatment. Until details of medical condition has been obtained Patient’s physician has been consulted Antibiotic Prophylaxis ✓If dental procedures are likely to induce bacteremia, then prophylactic antibiotic therapy is required to prevent development of endocarditis. ✓Any procedure that breaches the integrity of oral mucosa or which exposes the pulp is a risk Extractions Scaling Surgery involving gingiva Restorative procedures where gingival margins maybe traumatized Cavity preparation Matrix band placement Antibiotic Prophylaxis Oral antibiotic: Amoxicillin Adults: 2gs Children: 50 mg/Kg Or Parental antibiotic: Amoxicillin or ceftriaxone Adults: 2g IM/IV Children: 50mg/kg IM /IV Infective Endocarditis the vegetation Infective Endocarditis Acute Subacute Infective Endocarditis Infective Endocarditis Infective Endocarditis Pathogenesis Endothelial damage Platelet-fibrin thrombi Microorganism adherence Prophylaxis Standard Regimen Amoxicillin 2g PO 1h before procedure or Ampicillin 2g IM/IV 30m before procedure Penicillin Allergic Clindamycin 600 mg PO 1h before procedure or 600 mg IV 30m before Cephalexin OR Cefadroxil 2g PO 1 hour before Cefazolin 1.0g IM/IV 30 min before procedure Azithromycin or Clarithromycin 500mg PO 1h before procedure Bleeding Disorders Types Therapeutic Anticoagulants Hereditary Coagulopathies Dental Management (Coagulopathy) ✓Defer surgery until a hematologist is consulted about the patient’s management. ✓Have baseline coagulation tests, as indicated (prothrombin time, partial thromboplastin time, bleeding time, platelet count), and screening for hepatitis performed. ✓Schedule the surgery in a manner that allows it to be performed soon after any coagulation-correcting measures have been taken (after platelet transfusion, factor replacement, or aminocaproic acid administration). Dental Management (Coagulapathy) oBleeding time: Normal 1-6 minutes Prolonged on patients with platelets abnormalities or taking drug affecting platelet function es: asprin. oClotting time: Normal 8-15 minutes Dental Management (Coagulapathy) oProthrombin time (PT): Normal 10-15 seconds Indicates levels of factor VII and( V , X, prothrombine and fibrinogen Mostly monitor warfarin. Dental Management (Coagulapathy) oPartial thromboplastin time (PTT) time: Normal 25-35 seconds. Measures intrinsic pathway for all factors except VII Monitor Heparin Dental Management (Coagulapathy) oInternational Normalized Ratio (INR): Normal =1 INR 2-3: therapeutic range. INR 2 : minimal bleeding. INR 3-4.4: excessive bleeding. Work till INR 3 but not more , simple procedures, local hemostatic measures if more don’t operate. Dental Management (Coagulapathy) ✓Augment clotting during surgery with the use of topical coagulation-promoting substances, sutures, and well-placed pressure packs. ✓Monitor the wound for 2 hours to ensure that a good initial clot forms. ✓Instruct the patient on ways to prevent dislodgment of the clot and on what to do should bleeding restart. Dental Management(Therapeutic) Patients Receiving Aspirin or Other Platelet-Inhibiting Drugs Defer surgery until the platelet-inhibiting drugs have been stopped for 5 days but now it’s not stopped. Take extra measures during and after surgery to help promote clot formation and retention. Dental Management(Therapeutic) Patients Receiving Warfarin (Coumadin) Consult the patient’s physician to determine the safety of allowing the prothrombin time (PT) to fall to 2.0 to 3.0 INR (international normalized ratio). May take a few days. (a) If the PT is less than 3.1 INR, proceed with surgery. (b) If the PT is more than 3.0 INR, Stop warfarin approximately 2 days before surgery Dental Management(Therapeutic) Patients Receiving Warfarin (Coumadin) Check the PT daily, and proceed with surgery on the day when the PT falls to 3.0 INR. Take extra measures during and after surgery to help promote clot formation and retention. Restart warfarin on the day of surgery. Dental Management(Therapeutic) Patients Receiving Heparin Consult the patient’s physician to determine the safety of stopping heparin for the perioperative period. Defer surgery until at least 6 hours after the heparin is stopped. Restart heparin once a good clot has formed. Haemophilia patients Sex linked disease (X-chromosome): ✓Males & usually discovered in young age. ✓Deficiency in factors VIII or IX. ✓ Haemophilia A, there is a lack or total absence of coagulation factor VIII. In haemophilia B, there is a serious shortage or total absence of coagulation factor IX. Dental Management Preoperatively: Patient Should be Hospitalized Never work if anti-haemophilic globin less than 35% (if less blood transfusion or transfusion of missing factor). Dental Management Operatively: Local Anesthesia is preferred than General Anesthesia. Inhalational Anesthesia. Local Anesthesia with vasoconstrictor to decrease bleeding. Nerve blocks should be avoided and infiltration is preferred. Atraumatic procedures. Local hemostatic measures. Dental Management Postoperatively: Local hemostatic measures. No asprin adminstration. Management of Anemia and Thrombocytopenia Laboratory investigations ( CBC) for minimal complications Patient’s Hemoglobin should be above 11g/dl and patient should be free of symptoms ( short of breath ). Leukemia Leukemia is cancer of the WBC’s that affects the bone marrow and the circulating blood. Potential Medical problems: Bleeding : Local hemostatic measures. Infection (immature WBC’s): Prophylactic antibiotic. Delayed healing. Mucositis. Management of Leukemia Medical Consultation Avoid patients of acute symptoms. Avoid Procedure if platelets 15 days: Triple the dose the day before, day of surgery and the day after. Modulate vascular instability & reduce hypotension induced by stress Dental Management Keep a bronchodilator-containing inhaler easily accessible. Avoid the use of Nonsteroidal anti-inflammatory drugs (NSAIDs) in susceptible patients (induce bronchospasm). Chronic Obstructive Pulmonary Disease (COPD) COPD is usually caused by long-term exposure to pulmonary irritants such as tobacco smoke that cause metaplasia of pulmonary airway tissue. Airways are inflamed and disrupted, lose their elastic properties, and become obstructed because of mucosal edema, excessive secretions, and bronchospasm, producing the clinical manifestations of COPD. COPD ✓Patients with COPD frequently become dyspneic during mild to moderate exertion. ✓They have a chronic cough that produces large amounts of thick secretions, frequent respiratory tract infections, and barrel- shaped chests, and they may purse their lips to breathe and have audible wheezing during breathing. Remove the air that is trapped in lungs by slowing down the breathing rate and relieving shortness of breath. COPD ✓A barrel chest forms because the lungs are chronically overfilled with air and can't deflate normally. Dental Management ❖Defer treatment until lung function has improved and treatment is possible. ❖Listen to the chest bilaterally with stethoscope to determine adequacy of breath sounds. ❖Use an anxiety-reduction protocol, but avoid the use of respiratory depressants. Dental Management ❖If the patient requires chronic oxygen supplementation, continue at the prescribed flow rate. ❖If the patient does not require supplemental oxygen therapy, consult his or her physician before administering oxygen. Dental Management ❖If the patient chronically receives corticosteroid therapy, manage the patient for adrenal insufficiency. ✓ 5mg per day 15 days : Double the dose the day before, day of surgery and the day after. ✓40 mg < 15 days: Double the dose the day before, day of surgery and the day after. ✓40 mg > 15 days: Triple the dose the day before, day of surgery and the day after. Dental Management ❖Avoid placing the patient in the supine position until you are confident that the patient can tolerate it. Dental Management ❖Keep a bronchodilator-containing inhaler accessible. ❖Closely monitor respiratory and heart rates. ❖Schedule afternoon appointments to allow for clearance of secretions. Removing ✓ Waste products (urea, toxins, uric acid). ✓ Extra water from the blood (urine). ✓ Ensure proper balance of key chemical elements such as sodium, potassium, calcium. Dental Management ❑Avoid the use of drugs that depend on renal metabolism or excretion. (use amide type L.A) ❑Modify the dose if such drugs are necessary. ❑Avoid the use of nephrotoxic drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). ❑Defer dental care until the day after dialysis has been given. Dental Management ❑Consult the patient’s physician about the use of prophylactic antibiotics (may be nephrotoxic). ❑Monitor blood pressure and heart rate. ❑Look for signs of secondary hyperparathyroidism (Loss of lamina dura and widening of the periodontal ligament spaces, and late signs as cortical bone destruction and tooth displacement). Dental Management ❑Consider screening for hepatitis C virus before dental treatment. (may be transmitted by the dialysis). ❑Take the necessary precautions if unable to screen for hepatitis. These viral components will typically get attacked by antibodies to fight the infection. Once this happens, the antibodies will bind with the virus, and the resultant debris will get deposited in the kidney. It can then set off an inflammatory reaction, which could cause kidney damage. Organ Transplant Patients Most commonly receive ✓Corticosteroids ✓Immuno-suppressive drug ✓Cyclosporine A (immunosuppressant medication) ✓Anti-hypertensive drugs Dental Management Defer treatment until the patient’s Avoid the use Consider the Monitor blood primary care physician or of nephrotoxic pressure. use of transplant surgeon clears the drugs. supplemental patient for dental care. corticosteroids. Dental Management oConsider screening for hepatitis B virus before dental care. Take necessary precautions if unable to screen for hepatitis. oWatch for presence of cyclosporine A–induced gingival hyperplasia. Emphasize the importance of oral hygiene. oConsider use of prophylactic antibiotics, particularly in patients taking immunosuppressive agents. Epilepsy Dental Management Better operate under General Anaesthesia and if under local anesthesia use mouth gag. Work 2 weeks from last attack. If seizure occurs while working: ✓ stop procedures and remove instruments from patient’s mouth. ✓ Try to place the patient on floor in recovery position to keep airway. Dental Management ✓Defer elective surgery until after delivery, if possible. ✓Safest to work at 2nd trimester. ✓Consult the patient’s obstetrician if surgery cannot be delayed. ✓Avoid dental radiographs. ✓ Stress reduction protocol. Dental Management ✓Avoid the use of drugs with teratogenic potential. Use local anesthetics when anesthesia is necessary. ✓Avoid keeping the patient in the supine position for long periods, to prevent vena caval compression (supine hypotension). ✓Allow the patient to take trips to the restroom as often as needed. Dental Management ✓Fainting and syncope: Patient should be placed on her left side to increase venous return and cardiac output. AIDS Dental Management Last appointment and Infection control measures. Disposable instruments. If not disposable tools should be washed and immersed in 2% glutaraldehyde for 24 hours before autoclaving. If impression avoid alginate (syneresis and imbibition) instead silicon and rubber base. Chemotherapy and Radiotherapy Dental Management ✓Prevention of any complication : Removal of all septic foci before administration of chemotherapy or radiotherapy. ✓Avoid extractions to avoid osteoradionecrosis. If extraction at least 6 months after last dose ( to allow regeneration of blood supply). ✓For chemotherapy: Consultation to know the exact chemotherapeutic drug and any adjuvante drug therapy (ex: bisphosphonates) because some drugs (have a long half life time (up to 10 years). Will lead to Bisphosphonate Related Osteonecrosis of the Jaw(BRONJ).

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