Periodontics Management of Medically Compromised Patients PDF

Periodontics Periodontal management of medically compromised patients The learning objectives 1- Identify and understand various medical conditions that may impact periodontal health. 2- Develop skills in obtaining a thorough medical history from patients. 3- Develop treatment plans tha...

Periodontics Periodontal management of medically compromised patients The learning objectives 1- Identify and understand various medical conditions that may impact periodontal health. 2- Develop skills in obtaining a thorough medical history from patients. 3- Develop treatment plans that consider the patient's medical condition. 4- Understand the impact of medications on periodontal health and how to manage potential side effects or interactions. Many patients seeking dental care have significant medical conditions that can alter the course of their oral disease and the therapy provided. Older periodontal patients are more likely to have underlying disease. The therapeutic responsibility of the clinician includes identification of the patient's medical problems to formulate a proper treatment plan. A thorough medical history is paramount. Because of the increasing numbers of dental patients, especially among older adults who have chronic medical problems, dentists must remain knowledgeable about a wide range of medical conditions and drug considerations. Many chronic disorders or their treatments necessitate alterations in the provision of dental treatment. Failure to make appropriate treatment modifications may have serious clinical consequences, if significant findings are unveiled, consultation with or referral of the patient to an appropriate physician is indicated. This ensures correct management and provides medicolegal coverage for the clinician.  The fundamental question that must be addressed is whether the benefit of dental treatment outweighs the risk of a medical complication occurring either during treatment or as a result of treatment. Treating the medically compromised patient is a complex part of dentistry , requiring competent practitioners with many attributes : sound technical skills ,insight into medicine, familiarity with pharmacotherapeutics, and the capability of analyzing findings from patient histories and signs and symptoms. From the most common medical problems are the following: - 1. Cardio-vascular diseases:- These diseases are the most prevalent category of systemic disease and more common with increasing age. They include hypertension, angina pectoris, myocardial infarction, previous cerebrovascular accident, congestive heart failure, presence of cardiac pacemakers and infective endocarditis. In most cases the patient's physician should be consulted, especially if stressful or prolonged treatment is anticipated. Short appointments and a calm, relaxing environment help to minimize stress. a) Hypertension:- In accordance with most major guidelines it is recommended that hypertension be diagnosed when a person’s systolic blood pressure (SBP) in the office or clinic is ≥140 mm Hg and/or their diastolic blood pressure (DBP) is ≥90 mm Hg following repeated examination (AHA guidelines, 2020), which mean it is not diagnosed on a single elevated blood pressure recording but it's based on the average value of three or more blood pressure readings taken at three or more appointments. Hypertension is an important modifiable cardiovascular risk factor and therefore all measures aimed at identifying and controlling its development and progression are a global public health priority If hypertension persist and increase in severity, it may lead to coronary heart disease, angina, congestive heart failure, cerebrovascular accident or kidney failure. Management of those patients will be as follows:- 1) No periodontal treatment should be given to a patient who is hypertensive  and not under the medical management. 2 ) Stress free, calm and relaxing environment with short appointments. 3 ) The dentist should inform the physician about the degree of stress, blood loss and length of the periodontal procedure so that to avoid excessive bleeding. 4) Local anesthesia without epinephrine may be used for short procedures (less than 30 minutes). Local anesthesia with vasoconstrictor and hypertension has been reviewed in literature, epinephrine is the most commonly used vasoconstrictor agent in dental treatment. The use of 1 to 2 cartridges of LA with 1:80,000, 1:100,000 or 1:200,000 of epinephrine in patients with controlled Hypertension and/or Coronary disease is safe to control pain and minimize stress. (Dental treatment for hypertensive patients is generally safe as long as stress is minimized). 5 ) Postural hypotension is common with patients on antihypertensive medication and can be minimized by slow positional changes in dental chair. b) Angina pectoris:- Angina occurs when myocardial oxygen demand exceeds supply, resulting in temporary myocardial ischemia. Patients with a history of unstable angina pectoris (angina that occurs irregularly or on multiple occasions without predisposing factors) should be treated for emergencies only and in consultation with the patient’s physician. Because stress often induces an acute anginal attack, stress reduction is important. Profound local anesthesia is vital, and conscious sedation may be indicated for anxious patients. Patients who manage acute anginal attacks with nitroglycerin should be instructed to bring their medication to dental appointments. Nitroglycerin should also be kept in the office medical emergency kit Patients with a history of stable (angina that is associated with stress and easily controlled with medication and rest) can be treated with the following precautions:- 1) Premedication if needed as valium.  2) Short appointments. 3) Nitroglycerine medication sublingually 5 minutes before the procedure. 4 )If a patient with a history of angina experiences chest pain during the periodontal surgery, the treatment must be stopped; the patient should be given glyceryl trinitrate 0.3 – 0.6 mg sublingually and oxygen and be kept sitting upright. 5) If the signs and symptoms cease within 3 minutes, complete the periodontal procedure if possible, making sure that the patient is comfortable. Terminate the procedure at the earliest convenient time. 6)If the anginal signs and symptoms do not resolve with this treatment within 5 minutes, administer another dose of nitroglycerin, monitor the patient's vital signs, call the patient's physician, and be ready to accompany the patient to the emergency department. 7) A third nitroglycerin tablet can be given 5 minutes after the second. The patient should be transported to the nearest emergency medical facility. c) Myocardial infarction (MI) :- MI is the other category of ischemic heart disease encountered in dental practice. Periodontal treatment should not be done for at least 6 months following myocardial infarction because the peak mortality rate occurs during this time. After 6 months, the patient can be usually using the similar precautions of stable angina patient. d) Previous cerebrovascular accident (CVA):- CVA or stroke occurs as a result of ischemic changes (e.g. cerebral thrombosis). Hypertension and atherosclerosis are predisposing factors to a CVA. Cerebrovascular accident is one of the leading causes of death with a recent increase in its incidence. Approximately 5.9 million people died of stroke in 2010 and the figure is expected to reach approximately 7.8 million by 2030. In a meta-analysis on the oral health for patients with stroke they concluded that stroke patients had poorer oral health. Considering the negative consequences of poor oral health, further research and regular screening for oral health problems in clinical practice should be a standard part of the care of stroke patients including regular oral examinations, oral health education, and dental treatment. The periodontal management include the following:- 1) No periodontal therapy should be performed for 6 months after the stroke  because of high risk of recurrence during this period. 2) After 6 months, periodontal therapy may be performed with short appointments and minimal stress. 3) Profound(deep) local anesthesia should be obtained, using the minimal effective dose of local anesthetic agents. Concentrations of epinephrine greater than 1: 100,000 are contraindicated 4) Those patients usually are placed on oral anticoagulants.Previously, it was thought that for procedures entailing significant bleeding, such as periodontal surgery, the anticoagulant regimen might need adjustment, depending on the level of anticoagulation at which the patient is maintained. However, evidence regarding the risks of altering anticoagulation therapy suggests that it may be careful to provide treatment without changing it. Changes in anticoagulant therapy regimens for a stroke patient should be done in consultation with the patient's physician, also must check the prothrombine time not more than 1.5 times normal (11-15 seconds normally). 5) Monitor the blood pressure because of recurrence rate of CVA is high. e- Congestive heart failure:- Is a condition in which the pump function of the heart is unable to supply sufficient amounts of oxygenated blood to meet the body’s needs. The guidelines by the American College of Cardiology/ American Heart Association (ACC/AHA) suggest that patients with decompensated HF constitute a major risk for the occurrence of a serious event (acute MI, unstable angina, or sudden death) during treatment. Thus, patients with symptoms of HF generally are not candidates for elective(usuall) dental care, and treatment should be postponed until medical consultation can be obtained. Those patients may have ventricular assist device (VAD) which is a mechanical pump that's used to support heart function and blood flow in people who have weakened hearts. The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would. Patients with treated congestive heart failure should be manages as follows:- 1) The patients taking diuretics so watch for susceptibility to orthostatic hypotension. 2) The patients taking dicumarol which is anticoagulant so consult with the  physician to check prothrombin time. 3) The procedures should be short with less stress. f- Cardiac pacemakers:- Some cardiac arrhythmias are treated with implantable pacemakers which usually implanted in the chest wall and enter the heart transvenously. These electrical devices are used to regulate heart beats and an electro- physiologic problems may occur with such implanted device. Management of such patients will be as follows:- 1) Consult with the physician to get information about the underlying cardiac reason for pacing and to explain the periodontal treatment plan to him. 2) The patient should be positioned so that minimal pressure will be exerted on the implant site. 3) Limited use of electrical dental equipment that generates electromagnetic fields such as ultrasonic devices so that to avoid interference with the artificial pacemakers. Try to keep these devices at least 30 cm from the patient. However, most pacemakers are adequately shielded to prevent these changes.It is advisable that dentists should consider the use of hand instruments for scaling and root planing for patients who have pacemakers. g- Infective endocarditis IE:- It's a disease in which microorganisms colonize the damaged endocardium or heart valve. It is a serious disease with poor prognosis. IE classification is based on the causative microorganism (e.g., streptococcal endocarditis, staphylococcal endocarditis, candidal endocarditis) and the type of valve that is infected (e.g., native valve endocarditis [NVE], prosthetic valve endocarditis [PVE]). Many organisms encountered with IE many of which could be transferred into the blood during an interventional procedure as a-hemolytic streptococci (e.g streptococcus viridans }. Other microorganisms found in the periodontal pockets and associated with this disease are Eikenella corrodens, Aggrigatibacteractinomycetemcomitans, Capnocytophaga and Lactobacillus species. IE also is classified according to the source of infection—that is, whether it is community acquired or hospital acquired—or whether the patient is an intravenous  drug user (IVDU). The practice of periodontics is intimately concerned with the prevention of IE. Any dental procedures that involve bleeding may induce a transient bacteremia, so prophylactic antibiotic should be recommended before the procedure which is associated with significant bleeding as periodontal surgery, scaling and root planing. However, bacteremia may occur even in the absence of dental procedures, especially in individuals with poor oral hygiene and significant periodontal inflammation. The preventive measures to reduce the risk of IE should consist of the following:- 1) Define the susceptible patient: Those patients at high risk to develop IE following dental treatment include those with rheumatic heart disease, congenital heart disease, cardiac surgery, prosthetic heart valves. 2) Provide oral hygiene instruction: in patients with significant gingival inflammation, oral hygiene should be initially limited to gentle procedures (i.e oral rinses as chlorhexidin mouth rinse and gentle tooth brushing with soft brush). As gingival health improves, more aggressive oral hygiene may be initiated. 3) During periodontal treatment, recommended prophylactic antibiotic regimens should be practiced with all susceptible patients. The regiment used is the following:-  Regimen Antibiotic Dosage Standard oral Amoxicillin 2 g one hour before regimen procedure Alternate regimen for Clindamycin 600 mg one hour before patients allergic to or procedure amoxicillin or Azith mycin penicillin 500 mg one hour before or procedure Cephalexin 2.0 g one hour before (Cephalosporins) procedure ro Patient unable to Ampicillin 2 g intramuscularly or take oral medication intravenously within 30 minutes before procedure 600 mg intravenously Patients unable to Clindamycin within 30 minutes before take oral medications procedure (must be and allergic to diluted and injected penicillin slowly) Or 1.0 g intramuscularly or Cefazolin intravenously within 30 minutes before procedure 4) Periodontal treatment should be designed according to the degree of severity and involvement of periodontal tissues:- Periodontal therapy is a prolonged procedure, it is mostly not a one day antibiotic regimen, multiple visits and easily elicit gingival bleeding, so periodontal treatment plans must be developed for patients susceptible to IE and as follows:- a. In order to reduce the wide range systemic effect of periodontal disease in these patients, teeth with severe periodontitis and poor prognosis have to be extracted rather than retained and treated. b. Pretreatment chlorhexidin mouth rinse are recommended before all procedures because it reduce the presence of bacteria on mucosal surfaces. c. Reduce the number of visits required so that to minimize the risk of developing resistant bacteria. d. It’s preferably that the appointments allowed between 10-14 days, if it's not possible then select an alternative antibiotic regimen. e. The need for antibiotic prophylaxis before suture removal is controversial when possible use the resorbable sutures in such patients. f. Regular recall appointments are important with reinforcement on good oral hygiene to maintain periodontal health. In summary Cardiac Conditions associated with the Highest Risk of Adverse Outcomes from Endocarditis for Which Prophylaxis with Dental Procedures Is Recommended: Prosthetic cardiac valve Previous infective endocarditis Congenital heart disease (CHD)* Completely repaired CHD with prosthetic material or device by surgery or catheter intervention during the first 6 months after the procedure. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device, which inhibits endothelialization Cardiac transplant recipients who develop cardiac valvulopathy 2. Renal disease:- Patients with chronic renal failure have a progressive disease that may require kidney transplantation or dialysis. The patients who are receiving hemodialysis require special precautions. Those patients have a high incidence of viral hepatitis, anemia and prolonged hemorrhage. The risk of hemorrhage is related to anticoagulant during dialysis. Also they have either an internal arteriovenous fistula or an external arteriovenous shunt. This shunt is often located in the arm and must be protected from trauma. The management of those patients will be as follows:- 1) Consult with patient's physician. 2) Screen for hepatitis B surface antigen and antibodies prior to any treatment. 3) Avoid drugs that metabolized by the kidney ex. Tetracycline, streptomycin, aminoglycoside, aspirin... etc. 4) Provide antibiotic prophylaxis to prevent infective endarteritis. 5) Check blood pressure, blood urea nitrogen, serum creatinine,bleeding time, platelet count, partial thromboplastin time. (normally bleeding time = 1-6 seconds, platelet count = 140,000- 400,000/mm3). 6) Patients receive heparin anticoagulation on the day of hemodialysis, Periodontal treatment should be provided on the day after dialysis, when the effects of heparinization have subsided. Hemodialysis treatments are usually performed three or four times per week. 7) If arteriovenous fistula/shunt is present in the arm, blood pressure readings should be taken from the other arm. If A-V fistula is present in leg, patient is asked to avoid sitting with the leg dependent for longer than one hour. Patients with renal transplantation take immnosupressive drugs that greatly reduce resistance to infection. Excessive bleeding can occur during or after periodontal treatment because of drug-induced thrombocytopenia or anticoagulation, or both. So management of those patients will be as follows:- 1) Prophylactic antibiotic to prevent infection (prescribed by the physician). 2) May need supplemental corticosteroid. 3) Teeth with severe bone and attachment loss, furcation invasion, periodontal abscesses, or extensive surgical requirements should be extracted, leaving an easily maintainable dentition before transplantation to reduce possibility of infection. 4) Surgical excision of the gingiva may be needed because of gingival overgrowth secondary to cyclosporine therapy (preferably in the hospital under the supervision of the physician to control excessive bleeding). 3- Chemotherapy is a type of cancer treatment that uses one or more anti- cancer drugs (chemotherapeutic agents) as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent (which almost always involves combinations of drugs), or it  may aim to prolong life or to reduce symptoms (palliative chemotherapy). What precautions should be taken while treating the patient undergoing chemotherapy? (1) Consult patient’s physician. (2) The treatment should be conservative and palliative. (3) Periodontal therapy is best done the day before chemotherapy is given, as WBC count is relatively high on that day. It should be done when WBC count are above 2000/mm3 with an absolute granulocyte count of 1000 to 1500/mm3. 4) Complete blood count is important o Not enough red blood cells causes anemia. Symptoms include fatigue, dizziness, and shortness of breath. o Not enough white blood cells causes leukopenia. This raises the risk of getting infections. If this happens, the patient need antibiotics as soon as possible.  Platelet count. This test measures the number of platelets in the blood. Platelets are cells that stop bleeding. o Not having enough platelets causes thrombocytopenia. The patient can bleed and bruise more easily than normal. The learning outcomes prepare dental professionals to deliver high-quality care while considering the complexities associated with managing periodontal health in individuals with various medical conditions. References Newman and Carranza's Clinical Periodontology, thirteen edition