Periodontal Treatment in Medically Compromised Patients PDF

7.11.2023 Periodontal Treatment in Medically Compromised Patients Assisst. Prof. Ece RAKUNT TOPTAŞ School of Dental Medicine Department of Periodontology Istanbul [email protected] 1 Resources Newman and Carranza`s Clinical Periodontology Newman Takei Klokkevold Carranza Chapter 39 2 1...

7.11.2023 Periodontal Treatment in Medically Compromised Patients Assisst. Prof. Ece RAKUNT TOPTAŞ School of Dental Medicine Department of Periodontology Istanbul [email protected] 1 Resources Newman and Carranza`s Clinical Periodontology Newman Takei Klokkevold Carranza Chapter 39 2 1 7.11.2023 CARDIOVASCULAR DISEASES Hypertension!!! Angina Pectoris Myocardial Infraction (MI) Cardiac bypass surgery Cerebrovascular Accident Congestive Heart Failure Infective Endocarditis Implanted Cardiac Pacemaker/Automatic Cardioverter Defibrillators 3 v Hypertension 4 2 7.11.2023 Hypertension ØDo not diagnose hypertension from a single elevated BP recording ØTwo or more BP (10 minutes apart) should be taken at two or more appointments ØDental treatment is safe as long as stress is minimized ØLower BP levels occur in the afternoon , appointments should be scheduled in the afternoon 5 Hypertension Ø It is important to minimize pain by local anesthesia to prevent an increase in endogenous epinephrine secretion Ø Local anesthesia without epinephrine can be used for short procedures (<30 minutes)?? Ø In other treatments local anesthetic containing an epinephrine concentration greater than 1 : 100,000 should be used Side effects of hypertensive medications; • Nausea • Oral dryness • Gingival overgrowthà WHICH MEDICATION??? • Postural hypotension (can be minimized by slow positional changes) 6 3 7.11.2023 v Ischemic Heart Disease Unstable (occurs irregularly/without predisposing factor) Only emergency treatment Stable (occurs infrequently/stress Stress reduction is important Angina Pectoris stimulates/easily controlled with medication) 7 Angina Pectoris ØPatients using nitroglycerin should bring their medication to dental appointments ØNitroglycerin should be kept in medical emergency kit (be careful with the shelf life!!) ØFor stressful procedures, nitroglycerin can be given preoperatively ØPatients with angina may use antihypertensive drugs (side effects/local anaesthesia) 8 4 7.11.2023 v In case of Angina Pectoris during dental procedure 1.Discontinue the periodontal procedure 2. Administer 1 tablet (0.3 to 0.6 mg) of nitroglycerin sublingually 3. Reassure the patient, and loosen restrictive garments 4. Administer oxygen with the patient in a reclined position 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. Chest pain that is not relieved by three tablets of nitroglycerin indicates likely MI. The patient should be transported to the nearest emergency medical facility immediately 9 v Ischemic Heart Disease (MI) Myocard Infarction First 6 months Postpone dental treatments After 6 months Treat like stable angina patients 10 5 7.11.2023 v Infective Endocarditis Disease which microorganisms colonize damaged endocardium or heart valves. Bacteremia may occur in the absence of dental procedures, especially in individuals with poor oral hygiene and significant periodontal inflammation. IE is much more likely to result from frequent exposure to bacteremias associated with daily activities than be caused by a dental procedure. Our major concern should reduce the microbial population in the oral cavity to minimize soft tissue inflammation and bacteremia. 11 v Infective Endocarditis 12 6 7.11.2023 v Infective Endocarditis 13 v Infective Endocarditis (What should we do in case of IE risk?) Teeth with severe periodontitis and poor prognosis may require extraction All periodontal treatment procedures (including probing) require antibiotic prophylaxis Pretreatment chlorhexidine rinses are recommended before all procedures, including periodontal probing, because these oral rinses significantly reduce the bacteria on mucosal surfaces. When possible, allow at least 7 days between appointments (preferably 10 to 14 days). If this is not possible, select an alternative antibiotic regimen for appointments within a 7-day period. If the periodontal patient is taking a systemic antibiotic as part of periodontal therapy, changes in the IE prophylaxis regimen may be indicated. 14 7 7.11.2023 Cardiac Pacemaker Older pacemakers were unipolar and could be disrupted by dental equipment that generated electromagnetic fields, such as ultrasonic and electrocautery units Newer units are bipolar and are usually not affected by dental equipment 15 Diabetes No advanced treatments The classic signs of diabetes are; 1.Polydipsia 2.Polyuria 3.Polyphagia Consult physician Nonsurgical periodontal therapy + oral hygiene education Analyze Blood Test Acute oral infection/ provide emergency care 16 8 7.11.2023 v Diabetes Ø Fasting plasma glucose level ≥ 126mg/d Ø Random plasma glucose level ≥ 200mg/dL Ø Glycated hemoglobin (HbA1c) value ≥ 6.5% Blood glucose concentration at the time the blood was drawn Long-term glycemic control. 17 v Diabetes ØPatients with relatively well-controlled diabetes (HbA1c <8%) usually respond to therapy similar to nondiabetic individuals \ ØSupportive antibiotic therapy are not needed routinely but evidence indicates that Tetracycline + SRP positively influence glycemic control ØPoorly controlled patients (HbA1c >10%) often have a poor response to treatment, with more postoperative complications and less favorable long-term results ØIf the patient has poor glycemic control and surgery is needed, prophylactic antibiotics can be given; penicillins are often preffered 18 9 7.11.2023 Patients with uncontrolled diabetes; Patients should bring their glucometer Blood glucose level should be checked before long procedure < normal = patient may become hypoglycemic introperatively Consume some carbohydrate before starting >normal =check Hba1c/ poor glycemic control? 19 Ø If patient feels the symptoms of hypoglycemia during treatment; blood glucose levels should be checked immediately (<60 mg/dl is hypoglycemia, <20 mg/dl causes death) 20 10 7.11.2023 In case of hypoglysemia attacks 1.Provide 15 gr of oral carbohydrate (juice/soda, 3-4 teaspoons of sugar, candy) 2.If patient is unable to take food or drink by mouth; ØGive 25 to 30 mL of 50% dextrose intravenously ØGive 1 mg of glucagon intravenously/intramuscularly 21 How to avoid hypoglycemia attacks? ØWe should avoid peak insulin activity while planning periodontal treatment times Ø Which insulin, amount and number of times per day, time of the last dose Ø Question past episodes of hypoglycemia Ø Taking insulin without eating is the primary cause of hypoglycemia Ø Patients should eat normal meal before dental treatment Ø If the procedure is going to be long, the insulin dose before treatment may be reduced 22 11 7.11.2023 How to avoid hypoglycemia attacks? As a general guideline, well-controlled diabetic patients having routine periodontal treatment should take their normal insulin doses and also eat their normal meal 23 Ø Hypoglycemia attacks are more often than hyperglycemia attacks in dental treatments Ø Hypoglycemia is more common in patients with better glycemic control Ø It takes days to develop hyperglycemia; Ø Diabetic ketoacidosis occurring due to hyperglycemia causes life-threatening event 24 12 7.11.2023 vCoagulation Disorders We should ask; 1. 2. 3. 4. The history of bleeding after previous surgery or trauma, Past and current drug history History of bleeding problems among relatives Illnesses associated with potential bleeding problems (Heomophilia A and B, von Willebrand disease Clinically; 1. Ecchymosis, 2. Petechiae, 3. Hemorrhagic vesicles, 4. Spontaneous gingival bleeding, 5. Gingival hyperplasia 25 vCoagulation Disorders ØHemophilia A and B, Von Willebrand disease Ø Most coagulation factors are synthesized and removed by the liver; Ø Liver disease Ø Long-term alcohol abusers Ø Chronic hepatitis patients May have coagulation disorders Ø Anticoagulant/Antiplatelet therapy (patients with a prosthetic heart valve or a history of MI, CVA, or thromboembolism) 26 13 7.11.2023 Coagulation Disorders Ø INR (international normalized ratio); Ø Infiltration anesthesia, scaling, and root planning can be done safely in patients with an INR of less than 3.0. Ø Block anesthesia, minor periodontal surgery, and simple extractions usually require an INR of less than 2.0 to 2.5. Ø Complex surgery or multiple extractions may require an INR of less than 1.5 to 2.0. INR should be checked at the same day of treatment 27 vCoagulation Disorders (during periodontal presedures) Periodontal treatment can be performed in patients with these coagulation disorders Probing and scaling can usually be done without medical modification. More invasive treatment ,root planning, or surgery, needs prior physician consultation. 28 14 7.11.2023 vCoagulation Disorders (during periodontal presedures) During treatment, local measures to ensure clot formation and stability are of major importance Complete wound closure and application of pressure can reduce hemorrhage. Antihemostatic agents, such as oxidized cellulose or purified bovine collagen, can be placed over surgical sites or into extraction sockets. The anti fibrinolytic agent given orally or intravenously, is a potent inhibitor of initial clot dissolution. Tranexamic acid can prevent excessive oral hemorrhage after periodontal surgery and tooth extraction. It is available as an oral rinse and may be used alone or in combination with systemic tranexamic acid for several days after surgery. 29 vCoagulation Disorders Ø Aspirin typically is used in small doses of 325 mg or less per day, which usually does not alter bleeding time. Ø Patients taking low doses of aspirin daily usually do not need to discontinue aspirin therapy before periodontal procedures. Ø Higher doses can increase bleeding time and predispose the patient to postoperative bleeding. Ø Patients taking more than 325 mg of aspirin per day may need to be discontinued 7 to 10 days before surgical therapy this should be done in consultation with the physician. 30 15 7.11.2023 vCoagulation Disorders Aspirin typically is used in small doses of 325 mg or less per day, which usually does not alter bleeding time. Patients taking low doses of aspirin daily usually do not need to discontinue aspirin therapy before periodontal procedures. Higher doses can increase bleeding time and predispose the patient to postoperative bleeding. Patients taking more than 325 mg of aspirin per day may need to be discontinued 7 to 10 days before surgical therapy this should be done in consultation with the physician. 31 Patients will undergo; v Chemotherapy v Radiotherapy (especially head and neck) v Immunsupression therapy (organ transplantation) Extract all hopeless, nonmaintainable, or potentially infectious teeth (at least 10 days before the initiation of chemotherapy) Periodontal therapy (scaling and root planing) should be performed Twice-daily rinsing with 0.12% chlorhexidine gluconate is recommended after oral hygiene procedures. Administer antibiotic coverage before periodontal treatment if infection is a major concern 32 16