Medically Compromised Patient (Anous) PDF

Thyroid Diseases A. Hashimoto’s Thyroiditis Autoimmune disorder that manifests most often as an asymptomatic diffuse goiter Lymphocytes replace functioning tissue leading to hypothyroidism B. Hypothyroidism Signs and symptoms: Dull expression dry brittle and coarse h...

Thyroid Diseases A. Hashimoto’s Thyroiditis Autoimmune disorder that manifests most often as an asymptomatic diffuse goiter Lymphocytes replace functioning tissue leading to hypothyroidism B. Hypothyroidism Signs and symptoms: Dull expression dry brittle and coarse hair mental decline puffy eyelids increase in tongue size dry and rough skin cold sensitivity Considerations: Untreated hypothyroidism – sensitive to the actions of narcotics, barbiturates, and tranquilizers Stressful situations (cold, operations, infections or trauma) can precipitate a hypothyroid (myxedema) coma —> severe myxedema, bradycardia, severe hypotension C. Hyperthyroidism (Graves’ Disease) Autoimmune disease in which thyroid stimulating Igs bind to activate thyrotrophic receptors which increase gland growth and thus increase synthesis of T3 and T4 Signs and symptoms Nervousness heat intolerance fatigue weight loss rapid heartbeat/palpitations Atrial fibrillation in 20% of older patients D. Thyroid Storm Precipitating factors – infection, trauma, surgical emergencies, operations Early S/S: extreme restlessness, N&V, abdominal pain Later S/S: fever, diaphoresis, tachycardia, arrhythmias, pulmonary edema, and congestive heart failure. Coma may follow. Severe hypotension develops and death may occur Treatment: Antithyroid drugs (propylthiouracil), potassium iodide, propranolol, hydrocortisone, dexamethasone, IV glucose, vitamin B complex, wet packs, fans and ice packs Considerations: Avoid epi in poorly controlled patients Monitor BP NSAIDs may increase the amount of circulating T4 (use appropriately) 26 of 34 27 of 34 Pregnancy & Breastfeeding First trimester = organogenesis Fetus most susceptible to malformation Avoid treatment in the first trimester Patients may be insulin resistant (gestational DM) Breastfeeding: Most drugs prescribed will have little/no effect on milk supply or infant Considerations: Use lidocaine for local anesthetic (Avoid articaine, bupivacaine, mepivivaine) Avoid category C or D antibiotics Acetaminophen is the analgesic of choice Supine hypotensive syndrome Caused by impaired venous return due to compression of the inferior vena cava Sings and symptoms: Abrupt fall in BP nausea bradycardia weakness and air hunger in the supine sweating position Treatment: Roll patient to their left side Category A: Controlled studies in humans have failed to demonstrate a risk to the fetus, and the possibility of fetal harm appears remote. Category B: Animal studies have not indicated fetal risk, and human studies have not been conducted, or animal studies have shown a risk, but controlled human studies have not. Category C: Animal studies have shown a risk, but controlled human studies have not been conducted, or studies are not available in humans or animals. Category D: Positive evidence of human fetal risk exists, but in certain situations, the drug may be used despite its risk. Category X: Evidence of fetal abnormalities and fetal risk exists based on human experience, and the risk outweighs any possible benefit of use during pregnancy 28 of 34 29 of 34 Oncologic Considerations A. Cancer – Radiation & Chemotherapy Goal is to reduce risk of infection or osteoradionecrosis (ORN) Risk of ORN is greatest in: posterior mandible In patients who have received radiation doses >65 Gy Those who continue to smoke Those who have undergone a traumatic (eg. Extraction) procedure Considerations: Avoid epinephrine (to minimize hypovascularity after radiotherapy) Consider hyperbaric oxygen (HBO) Prophylactic Abx use Avoid extractions during radiotherapy Guidelines for Tooth Extraction in Patients Scheduled to Receive H&N Irradiation or Chemotherapy: Indicators for Extraction An emergency is an emergency Pocket depths 6mm or greater, excessive mobility, purulence on probing Presence of periapical inflammation Broken-down, non-restorable, non-functional, or partially erupted tooth with poor OH Patient lack of interest in saving teeth Inflammatory, infectious or malignant osseous disease associated with the tooth Chemotherapy Compromised immunity Kid. status Oral manifistations N/v (Nausea/ Vomiting) Bone marrow effect on WBC, neutrophils & platelets Extraction Guidelines At least 2 weeks prior to initiation of radiation therapy At least 5 days (maxilla) or 7 days (mandible) before initiation of chemotherapy Eliminate sharp edges Obtain primary closure Avoid packing agents (gel foam) which can become a nidus for bacterial growth Transfuse if the platelet count is less than 50,000/mm3 Delay extraction if the WBC is less than 2000/um or if the absolute neutrophil count is less than 1000/um Prophylactic antibiotics may be used if the extraction is necessary Antimicrobial (CHX m.w.) 30 of 34 MRONJ Definition 1. Current or previous treatment with antiresorptive or antangiogenic agents 2. Exposed bone or bone that can be probed through an intra/extra-oral fistula(e) in the maxillofacial region that has persisted for more than 8 weeks 3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws. Symptoms Pain Discomfort Teeth loss Burning sensation Stubborn Infection Halitosis Sensitivity Fistula/e formation BONE Avascular necrosis Discolored bone Loss of jaw/s Eroded soft tissue Bone shedding Creeping necrosis Exposed bone Sequestration Poor healing Management of MRONJ Prevention Vandore et al reported 50% dec. in ONJ in pts. Who were screened prior to drug therapy Necessary exos., denture adj., elective DA Sx Cessation of medication (drug holiday) Controversial AAOMS recommend Damm & Jones —> stop drug 2 months prior (level V evidence) 2009, 3m before & after or until osseous healing if O. BP >3ys Risk is higher after 4y No enough data to stop meds, need more studies. Pt. education O.BPs no alteration nor delay of DA Sx O.BPs drug holiday 2 months prior & not to be restarted until osseous healing occur O.BPs >4y +/- other meds —> drug holiday 2 months prior & not to be restarted until osseous healing occur *O.BP = Oral Bisphosphonates Case treatment sequence: Abs CHX OH optimize HBO (Hyperemic oxygen therapy dives) —> (total of 30 dives) Debridement Implant removal Daily irrigation 2nd debridement Daily irrigation Complete healing achieved in 2months 31 of 34 ORN (Osteoradionecrosis) Occur following surgical trauma to site or spontaneously Exposed bone fails to heal (6 months following RT) Endarteritis oblitrans —> Hypovascularity (hypocellular-hypovascular- hypoxia theory) R. MARX Soft tissue necrosis Bone necrosis Post. Mandible > Maxilla Due to less blood supp., dense cortical bone & more direct involvement of the mandible to RT Prevention & management 1. Appropriate dental check up 2wks prior to RT 2. Avoid exo. post RT (post. mandible more at risk) 3. Optimize oral hyg. (avoid aggressive brushing) 4. Ppx Abx, Pen. VK 2g 1hr pre-op, Cont. Pen VK 500mg p.o. qid X 1wk 5. Plain local anesthetic (no vasocon.) 6. HBO A. 20 pre-op dives B. 10 post-op dives 7. RCT when possible, avoid exo. Exo. should be as atrumatic as possible Avoid elevating the periosteum Limit exo to 2 teeth per appointment Irrigate with normal saline Primary closure No bony edges to be left 8. Post-op Hyg Mouth wash (warm salty water) CHX Fluoride gel No tobacco F/u q3m * Pen VK = Penicillin V Potassium * HPO (Hyperemic oxygen) 32 of 34 AIDS AIDS, stage 3 HIV infection CD4+ 200 cells/uL but have AIDS defining condition (e.g. Candidiasis, CMV, EBV, Kaposi, Burkitt, Myco-infections TB.....) Treatment: ART: Antiviral therapy HAART: Highly Active Antiretroviral Therapy (HAART) Chemoprophylaxis, CD4+ multiple vaccines given Oral manifistations oral hairy leukoplakia candida HSV ANUG HZV NUP linear gingival erythema Management Universal precautions, transmission 0.3% An emergency is an emergency Any oral lesion should be diagnosed Care in prescribing meds as hepatotox may occur AIDS with stage 3 HIV infection CD4+