All about examination and management of all medically compromised patients in dental clinic

Done by: Dr. Mohammad Salah Qrea D.D.S Al-Quds University Dental Faculty 2009

• There is no doubt that the first dental appointment is the most important dental visit, because during this visit we check the history of the patient clinically, in addition to several examinations that we always do, so that we can build our diagnosis and modify our dental treatment upon this.

What should we do in the first visit?
taking the patient personal data. Asking the patient about his\her chief

complain. Taking the medical history of the patient. Taking the dental history of the patient. Then “ THE EXAMINATION”.

Patients data
Name. Age. His\her address, and contact number. Gender. Occupation. Marital status.  

The chief complain
Very important because it will be our main goal of

treatment plan. History of chief complain:1-) the first appearance. 2-) description of PAIN (( onset, intensity, duration, location, and radiation.)) 3-) precipitating and relieving factors of pain. 4-) other symptoms such as fever, chills, lethargy, weakness,…etc that caused by this chief complain.

Medical history
Review for previous hospitalization. Review for serious illnesses and systemic

diseases. Review for Blood transfusion. Review for allergies. Review for Medications. Review for Pregnancy. Review for Habits.

The examinations
• 1-) dental examination. • 2-) physical examination. • 3-) management of medically compromised status.

DENTAL EXAMINATION

Teeth
The number of teeth. Alignment of the teeth. Caries. Periodontal status of the teeth. Non carious lesions “ abrasion, attrition, erosion,…etc” • And X-rays “ OPT, periapicals, bitewings, and occlusal.” • • • • • •

Bony tissues
• Checking the alignment of the mandible margins, hard palate, and buccal and lingual sulcus. • Any bony exostosis or tori. • Any swelling of tender areas within bone.

Soft tissues
• Salivary glands “ swelling, tenderness, amount of saliva, consistency of saliva, and others.” • Tongue “ movement, papillae, lateral borders, and ventral surface.” • Other cheek, soft palate, lips and floor of the mouth lesions. •
• Wait a PowerPoint presentation about “soft tissue lesions” from dr.mohammad salah qrea always on esnips.

Physical examination

What do we examine?
• Vital signs. • IPPA” inspection, palpation, percussion, and auscultation.” • Maxillofacial examination.” TMJ, lymph nodes, skin, MOM, cranial nerves,…etc”.

TMJ examination

Anatomy
• The Articulatory System is comprised of three components: the temporomandibular joints, the muscles of mastication and the occlusion (the nature contact between the upper and lower teeth).

We will examine...
• Tenderness to percussion. • Movement of the jaw, and the range of movement. • And sounds from the joint.

Tenderness to percussion
• A tenderness to palpation implies inflammation, generally as a result of acute or chronic trauma. • A finger should be placed in the immediate pre-auricular area, gently applying pressure on the lateral pole/head of the condyle while the jaw is closed. The level of pain and discomfort on each side should be assessed and compared. • The little finger should also be placed in the external auditory meatus, and

Palpation of the preauricular area of the temporomandibular joint.

Palpation of the intraauricular area of the temporomandibular joint

Joint sounds
• There are two sounds: • 1-) clicks “single explosive noise”. • 2-) crepitus “continuous 'grating' noise”.

Clicks
• A joint click probably represents the sudden distraction of 2 wet surfaces, symptomatic of some kind of disc displacement. • The diagnosis of a joint click, and therefore treatment, varies on whether the click is left, right or bilateral, painful or painless, consistent or intermittent. The timing of a click is also significant: a click heard later in the opening cycle may represent a greater degree of disc displacement. • Clicks may frequently be felt as well as

Crepitus
• Crepitus is the continuous noise during movement of the joint, caused by the articulatory surfaces of the joint being worn. This occurs most commonly in patients with degenerative joint disease. • The joint sounds should be listened to with a stethoscope, preferably a stereo one, as the two sides can be more easily compared. •

Range of motion
Movements to be measured are • Incisal opening - pain free limit • Incisal opening - maximum (forced) • Lateral mandibular excursions • Mandible deviations on pathway of opening

Incizal opening
• Pain free range means the incizal opening until the patient feel of pain or be uncomfortable. • Maximum forced opening, is important because we can determine the cause of opening limitation, if pain occur then the cause is the muscles, but if the physical obstruction limit the opening then the cause is disc

Lateral Excursions
• The lateral movement should be measured from mid-line to mid-line, the patient moving the mandible to their maximum extent, from one side to the other. • The mandibular deviation: • 1-) lasting deviation. • 2-) or tansient deviation.

Pain Dysfunction Syndrome
• Pain on palpatation of the TMJ • Pain on palpatation of the associated muscles • Limitation or deviation of mandibular movement • Joint sounds • Headache

Osteoarthrosis
• Joint sound due to crepitation (degeneration within surfaces of the joint or disc) • Limitation of jaw movement • Pain - usually located in the immediate pre-auricular region (not radiating to the surrounding muscles as with PDS)

Internal Derangement
• Joint click due to disc displacement or medical obstruction to mouth opening • Pain in later stages due to secondary muscle spasm

Trauma and dislocation
• External trauma to the face and jaws can often cause mandibular or condylar fracture or more commonly traumatic arthritis, but rarely is a cause of a chronic temporomandibular disorder. In the absence of an anatomical defect, dislocation is rare and usually caused by trauma.

EXAMINATION OF THE OCCLUSION

Occlusion= mandibular movement
• The mandible moves in relative to maxillae in two virtue of movement: • 1-) neuromuscular control. • 2-) and hard tissue guidance.

Neuromuscular control
• The masticatory muscles is the muscles that move the mandible during functional and parafunctional movements. • Electromypgraphy gives us a clear idea about these muscles movements.

Individual mandibular muscles The masseter muscle

Medial pterygoid muscle

Lateral pterygoid

Temporalis muscle

Digastric muscle

Mylohyoid muscle

Suprahyoid, infrahyoid and cervical muscles

Neural pathways
• Checking for voluntary and nonvoluntary movements, in addition to functional and non-functional movements.

Occlusion assessment
• • • • Three questions: Static occlusion. Does the CO occur in CR? Occluzal interferences.

The guidance systems
• Posterior guidance • Anterior guidance

P o ste rio r g u id a n ce

Anterior guidance

LYMPH nodes EXAMINATION

Palpation

    

Preauricular - In front of the ear Postauricular - Behind the ear Occipital - At the base of the skull Tonsillar - At the angle of the jaw Submandibular - Under the jaw on the side Submental - Under the jaw in the midline Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle

And then…
• Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, and mobile or fixed.

The head and face
Look for scars, lumps, rashes, hair loss, or other lesions. Look for facial asymmetry, involuntary movements, or edema. Palpate to identify any areas of tenderness or deformity. •

The ears
• Palpate the auricle and mastoid process and ask the patient for tenderness. • Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.

The nose
• Tilt the patient's head back slightly. Ask them to hold their breath for the next few seconds. • Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity.

Throat
Using a wooden tongue blade and a good light source, inspect the inside of the patients mouth including the buccal folds and under the tougue. Note any ulcers, white patches (leucoplakia), or other lesions. If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the mouth. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any tonsilar enlargement, redness, or discharge.

The neck
Inspect the neck for asymmetry, scars, or other lesions. Palpate the neck to detect areas of tenderness, deformity, or masses. •

Thyroid Gland
Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter. Move to a position behind the patient. Identify the cricoid cartilage with the fingers of both hands. Move downward two or three tracheal rings while palpating for the isthmus. Move laterally from the midline while palpating for the lobes of the thyroid. Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.

Thyroid examination

Facial Tenderness
Ask the patient to tell you if these maneuvers causes excessive discomfort or pain. Press upward under both eyebrows with your thumbs. Press upward under both maxilla with your thumbs. Excessive discomfort on one side or significant pain suggests sinusitis. •

Sinus Transillumination
Darken the room as much as possible. Place a bright otoscope or other point light source on the maxilla. Ask the patient to open their mouth and look for an orange glow on the hard palate. A decreased or absent glow suggests that the sinus is filled with something other than air.

The skin
Sore that never fully heals Translucent growth with rolled edges Brown or black streak underneath a nail Cluster of slow-growing, shiny pink or red lesions Waxy-feeling scar Flat or slightly depressed lesion that feels hard to the touch
 

The eyes
• Inspection: discoloration, redness, discharge, lesions, asymmetry, ptosis, exophthalmoses, lesions, or deformities. • Corneal Reflections • Extraocular Movement • •

Management of medically compromised patients in dental clinic

HEART DISEASES

Heart diseases in dentistry
• Cardiovascular diseases that should be managed peri-operatively in dentistry are: • Hypertension. • Ischemic heart diseases. • Dysrythmias. • infective endocarditis. • CVA. • CABG.

Ischemic heart diseases “ angina pectoris”
• Brief sub-sternal pain • Self-limiting with cessation of precipitating event • Precipitated by exercise, stress, eating, sex, etc • May occur at rest or while asleep

Clinical Patterns of Angina Pectoris • Stable- pain pattern and
characteristics relatively unchanged over past several months (better prognosis)

• Unstable - pain pattern
changing in occurrence, frequency, intensity, or duration (poorer prognosis); MI pending

Dental Management: Stable Angina/Post-MI >4-6 weeks
• • • • Minimize time in waiting room Short, morning appointments Measure vital signs. Pre-medication as needed
– anxiolytic (triazolam; oxazepam); night before and 1 hour before – Have nitroglycerin available .

• Use pulse oximeter to assure good breathing and oxygenation • Nitrous oxide/oxygen intraoperatively (if needed) • Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)

• 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

Dental Management: Unstable Angina or MI < 3 months

• • Give nitroglycerin • If after 5 minutes pain still present, give another nitroglycerin • If after 5 more minutes pain still present, give another nitroglycerin • If pain persists, assume MI in progress and activate the EMS
– Give aspirin tablet to chew and swallow – Monitor vital signs, administer oxygen, and be prepared to provide life support

Intraoperative Chest Pain Stop procedure

Medical Management of Angina
• Medications
– – – – – nitrates beta blockers calcium channel blockers anti-platelet agents antihyperlipidemics

• Surgery
– Percutaneous transluminal coronary angioplasty/ “balloon” angioplasty / stent – Coronary artery bypass graft (CABG)

Dental Considerations: *Nitrates*
• Vasoconstrictor Interactions:
– No clinically significant interactions

• Oral Manifestations:
– topical burning at site of contact

• Other Considerations:
– orthostatic hypotension and headache possible following administration

Beta Adrenergic Blockers
• These agents block either the beta-1 receptors predominately (cardioselective”CS”) or both the beta-1 and beta-2 receptors (nonselective”NS”) • Act as antiarryhthmics, decrease the heart rate, cardiac output, automaticity, and oxygen demand; also reduce peripheral resistance • Examples: propanolol (NS), nadolol (NS), sotolol (NS), timolol (NS), metoprolol

• While there is a potential for an enhanced hypertensive effect of epinephrine in a patient taking a nonselective beta blocker, it is clinically unlikely that such a reaction will occur • If a patient is taking a nonselective beta blocker (e.g. propanolol, sotolol), it is prudent to limit the amount of epinephrine administered to that found in two carpules of 1:100,000 concentration (0.036mg) • In patients taking a cardioselective beta blocker (e.g. metropolol), no limitations

Dental Considerations: Beta Blockers

Calcium Channel Blockers
• These agents block the channels that carry slow inward Ca++ currents in vascular smooth muscle and cardiac muscle • Resulting actions include the decrease of conduction velocity, reduction of automaticity, and coronary and peripheral arterial dilitation • These effects lead to an increase of coronary blood flow and a decrease in myocardial oxygen demand • Examples: nifedipine, verapamil, diltiazem, amlodipine

Dental Considerations: Calcium Channel Blockers
• There are no significant drug interactions reported • Gingival hyperplasia can occur in patients taking calcium channel blockers; close monitoring and encouragement of optimal oral

Antiplatelet Agents
• • • • • • Aspirin Clopidogrel (Plavix) Ticlopidine (Ticlid) Dipyridamole (Persantine) ASA+Dipyridamole (Aggrenox) Action: Decrease platelet aggregation and thus decrease chances of thrombus formation

Dental Considerations: Antiplatelet Agents
• With a single agent (e.g. aspirin, Plavix), expect some increased bleeding, but it is not usually clinically significant and can be managed by local measures such as pressure, suturing, stents, etc.; preoperative withdrawal is not justified • The combination of aspirin with other inhibitors of platelet aggregation increases the chances for significant bleeding; depending upon extent of surgery, it is advisable to discuss the risk/benefit of temporary discontinuation with the physician

Antihyperlipidemics
• HMG-CoA Reductase Inhibitors (“statins”) – Atorvastatin (Lipitor) – Fluvastatin (Lescol) – Lovastatin (Mevacor) – Pravastatin (Pravachol) – Rosuvastatin (Crestor) – Simvastatin (Zocor) • Cholestyramine (Questran) • Clofibrate (Abitrate; Atromid-S) • Colestipol (Colestid) • Gemfibrozil (Lopid) • Probucol (Lesterol; Lorelco)

Dental Considerations: HMG-CoA Reductase Inhibitors
• The combination of the HMG-CoA reductase inhibitors with erythromycin or clarithromycin may be associated with an increased risk of adverse drug effects on muscle (rhabdomyolosis) and kidney (acute renal failure). • Avoid concurrent use of HMG-CoA reductase inhibitors with erythromycin or clarithromycin.

Surgical Treatment
• Percutaneous Transluminal Coronary Angioplasty (PTCA) –balloon expansion that can provide 90%

Stent Placement
• With use of just the balloon, reocclusion of the artery can occur within months. • Placement of a stent delays or prevents reocclussion

Dental Considerations Balloon Angioplasty / Stent • These procedures are not associated with an increased risk of bacterial endocarditis or endarteritis. Therefore, antibiotics are not recommended following a balloon angioplasty nor are they recommended for patients with a stent.

Surgical Treatment
• Coronary Artery By-Pass Graft (CABG) • The graft bypasses the obstruction in the coronary artery • Graft sources:
– saphenous vein – internal

Dental Considerations: CABG

The CABG does not increase the risk for endocarditis , therefore antibiotic prophylaxis is not recommended.

Post-Myocardial Infarction

“MI”, “Coronary”, “Heart Attack” Infarction - an area of necrosis in tissue due to ischemia resulting from obstruction of


Sequelae and Complications of Acute MI
• Heart failure • Angina/infarct extension • Cardiogenic shock (inadequate perfusion) • Ventricular aneurysm and rupture • Arrhythmias • Thromboembolism

• Early hospital supportive care (EMS) • CCU monitoring • Early use of thrombolytics (Indicated only for
use in patients with ST-segment elevation MI).

Medical Management of Acute MI

• Coronary angioplasty (PTCA) • Coronary artery by-pass graft (CABG) • Adjunctive pharmacologic therapy (O2, narcotics, anxiolytics, beta-blockers, aspirin, heparin, warfarin, nitrates, calcium-channel blockers, digitalis, ACE inhibitors)

Clinical Predictors of Risk
• Major Risk:
– Unstable coronary syndromes • Recent myocardial infarction (< 1 month), with ischemic symptoms • Unstable or severe angina – CCS Class III: marked limitation with ordinary physical activity; climbing 1 flight of stairs at a normal pace – CCS Class IV: inability to carry on any physical activity without pain; may be present at rest – Significant arrhythmias: • A-V block • Symptomatic ventricular arrhthmias • Supraventricular arrhthmias with uncontrolled ventricular rate

• Intermediate Risk:
– Mild angina pectoris • CCS Class I: angina only with strenuous or rapid or prolonged exertion • CCS Class II: pain with climbing more than one flight of stairs at a normal pace – Previous myocardial infarction (> 1 month) with no ischemic symptoms – Compensated (asymptomatic) heart failure – Insulin-dependent diabetes mellitus – Renal insufficiency (creatinine > 2.0 mg/dl)

Dental Management Correlate • Elective dental care is ok if it has been longer than 46 weeks since the MI and the patient does not report any ischemic symptoms. • If there is any doubt or

Drug Therapy: Warfarin (Coumadin) Action: inhibits vitamin K which is a precursor for clotting factors II, VII, IX and X Dental treatment, including minor surgery, is unlikely to be problematic if INR is within the therapeutic

Periodontal Disease and Coronary Heart Disease
• There appears to be an association between PD and CHD; exact relationship unclear • Possibly related to the inflammatory effects of bacterial products, ie endotoxins, LPS; effect on endothelium; clot formation • Possibly no cause-effect relationship at all • Studies are underway to

?

Hypertension
• Hypertension is a persistently raised blood pressure resulting from increased peripheral arteriolar resistance. This condition is also known as hypertensive cardiovascular disease and hypertensive heart disease (HHD).

Dental management of hypertension
• Dental management in hypertensive patients can be complicated, since any procedure causing stress can further increase the blood pressure and can precipitate acute complications such as a cardiac arrest or a CVA. Chronic complications of hypertension, especially impaired renal function, can affect dental management.

C LA S S I C A T I N O F B LO O D P R E S S U R E I A D U LT S 1 8 O R O LD E R FI O N S Y S T O LI C C a te g o ry N o rm a lB P H i h N o rm a lB P g H yp e rte n si n o S ta g e I S ta g e I I S ta g e I I I S ta g e I V 1 4 0 -1 5 9 1 6 0 -1 7 9 1 8 0 -2 0 9 > 210 9 0 -9 9 1 0 0 -1 0 9 1 1 0 -1 1 9 > 120 P re ssu re ( m m H G ) < 130 1 3 0 -1 3 9 D I S T O LI A C P re ssu re ( m m H g ) < 85 8 5 -8 9

From the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 153:154-83, 1993

Side effects of some antihypertensive drugs
Xerostomia. Gingival overgrowth. Salivary gland swelling or pain. Lichenoid drug reactions. Erythema multiforme. Taste sense alteration. And paresthesia. •

Anesthesia ( local anesthesia )
• The local anesthesia should be perfect to reduce anxiety and pain during the procedure. • No epinephrine should be used with local anesthesia. • If we want to use very small doses of epinephrine we should inject it properly by using aspirating syringe, avoiding intrabony, or intralegamentary injections to

General anesthesia
• All antihypertensive drugs are potentiated by general anesthetic agents, especially barbiturates. • G.A. agents (such as ,halothane and isoflurane) tend to reduce the blood pressure significantly and this may be fatal to the patients organs that become adapted to raised blood pressure. • Hypokalemia as a result of diuretics may be associated with arrhythmias.

Anxiety control
• Anxiety reduction protocol. • Using of sedative agents pre and post operatively. • Relative analgesia technique using N2O, can reduce the blood pressure 10-15 mmHg. •

OTHER DENTAL CONCERNS
• Afternoon appointments are recommended over mornings. • Avoiding sudden postural changes, such as return to sitting position from the supine operating position. • Aspirin is now commonly taken by patients with hypertension. • Many patients with hypertension develop systolic heart murmurs, in which case prophylaxis for endocarditis

Endocrine diseases

Endocrine diseases
• • • • • Diabetes mellitus. Adrenal insufficiency. Hyperthyroidism. Hypothyroidism.

Diabetes mellitus
• Diabetes mellitus is a disorder characterized by impairment or destruction of the pancreas' ability to produce insulin and the resultant inability of the body to metabolize carbohydrates, fats, and proteins.

Clinical presentation
• There are two types of DM: • Type I Insulin Dependent Diabetes Mellitus, that occurs under age of 40 years. It is a severe, acute condition with a sudden onset of symptoms including: polydipsia, polyuria, nocturia, polyphagia, loss of weight, loss of strength, marked irritability, recurrence of bed wetting, drowsiness, and malaise.

Type II
• Non-Insulin Dependent Diabetes Mellitus, that occurs over the age of 40 years. • The primary manifestations are hyperglycemia, ketoacidosis, and vascular wall disease contribute to the inability of uncontrolled diabetic patients to manage infections and heal wounds. • Other signs and symptoms relating to the complications of diabetes are skin lesions, cataracts, blindness,

DENTAL MANAGEMENT
• Medical history: • Take a thorough medical history concerning the type of diabetes, and referral of any patient with cardinal diabetes symptoms to the physician. • Well controlled patients with no serious complications such as renal failure, hypertension, atherosclerosis,..etc, can receive any indicated dental treatment.

Avoiding sugar shock hypoglycemia
• The most dangerous thing in diabetetic patients during dental procedure is hypoglycemic shock, to prevent it do: • Verify the patient has taken his medication as usual, and adequate food intake. • Schedule appointments in the morning. • A source of sugar, such as orange juice, must be available in the dental office should the symptoms

Oral surgery concerns.
IDDM diabetics under periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection. Consultation with a patient's physician is advisable. The physician may, in fact, recommend that the patient be treated in a hospital environment where infection, bleeding, and dysglycemia can be better managed. •

Dangers of acute oral infection
• The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body's defenses as well as it would be in a non-diabetic patient. The patient's physician should become a partner in treatment during this period.

Oral complications
Xerostomia, Infection, Poor healing, Increased incidence and severity of periodontal disease, and Burning mouth syndrome. Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or pain in the oral region. •

Oral complications
• These complications are related to: • Excessive loss of fluids in oral cavity due to hyper urination. • Vascular changes in oral tissues. • Altered Infection response “immunity”. • And increased sugar concentrations in saliva. •

Potential Drug Interaction
• While patients with well-controlled diabetes can be given general anesthetics, management with local anesthetics is preferable. • General anesthetics should be used with caution because they can produce hyperglycemia.

Asthma

Preventing a sudden episode of airway obstruction is essential when treating an asthmatic patient

• Profound medical history: Frequency of asthmatic attack Precipitating agents Types of pharmacotherapy used Length of time since an emergency visit owing to acute asthma. Elective procedure can be performed in well controlled patients, but patients with symptoms should be referred to the physician. 

MANAGEMENT IN DENTAL CARE

Dental materials
• Dental materials that exacerbate asthma are: • Dentifrices. • Methylmethacrylates. • Sulfites. • Fissure sealants. • Fluoride trays and cotton roles. •

Dental management before treatment
Schedule appointments for late morning or afternoon. • Assess severity of asthmatic condition. • Consider antibiotic prophylaxis for immunosuppressed patients • Consider corticosteroid replacement for adrenally suppressed patients • Avoid using dental materials that may elicit an asthmatic attack • Have supplemental oxygen and bronchodilators available in case of acute asthmatic exacerbation

During treatment
• Use vasoconstrictors judiciously • Avoid using local anesthetics containing sodium metabisulfite • Use rubber dams cautiously • Avoid eliciting a coughing reflex • Use techniques to reduce the patient’s stress:
üAvoid using barbiturates üAvoid using nitrous oxide in people with severe asthma.

After treatment
Be aware that some patients may have an adverse reaction to nonsteroidal anti inflammatory drugs. • Use tetracycline cautiously. • Avoid use of erythromycin in patients taking theophylline. • Avoid use of phenobarbitals in patients taking theophylline. • Analgesic of choice for these patients is acetaminophen.

Chronic Obstructive Pulmonary Disease COPD
• Thorough medical history. • Most of these patients receive theophylline as bronchodilators “look at this in the previous slides”. • And other management process. •

Dental management of COPD
Well controlled disease. Physician consultation. Anxiety reduction protocol. Oxygen supplements. Suggest the presence of adrenal insufficiency. • Keep the emergency kit near containing bronchodilator inhalers. • Scheduling afternoon visits. • • • • • •

Renal failure and renal dialysis

Dental management of ESRD
• The patients physician should be consulted. • Screening of hematological disturbances. • Monitor blood pressure, and use good infection control protocol.

Medical considerations for patients receiving dialysis
• Consult the physician to determine if we need prophylactic antibiotics or not to prevent endocarditis. • Hemodialysis patients must avoid dental care on the day of dialysis, when they could have bleeding tendencies. The best time for dental treatment is the day after hemodialysis. • Suggest the presence of blood borne infections, due to blood dialysis.

Oral complications
• Pallor mucosa due to suggested anemia. • Loss of lamina dura. • Bone radiolucency. • Stomatitis. • Metallic taste. • Xerostomia.

Potential Drug Interactions.
Of special concern are drugs that are primarily excreted by the kidney or that are nephrotoxic (tetracycline, acyclovir, acetaminophen, aspirin, and NSAlDs). Certain drugs are removed during hemodialysis and, therefore, require an additional dose to be administered after hemodialysis. •

Renal transplant and other organs
• Preserve the function of transplanted organ. • Manage the corticosteroids supplements. • Limit the infections. • The cyclosporine A an immunosuppressive drug causes gingival hyperplasia. • And vital signs should be counted during and after the operation.

Pregnancy

Background
• Pregnancy has been considered an impediment to dental treatment. • However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning

Safety increasing
• Try to treat the pregnants during the 2nd trimester. • avoid major constructive surgery and periodontal surgery. • Radiography become safer due to use of high speed films, and aprons. • Ensure elective plaque control and preventive dental measures.

General guidelines
• In the first trimester, the dentist should not perform any elective procedures, with the exception of emergency dental care. • Pain and infection should be treated regardless of the trimester (root canals, extractions, etc.) • Routine dental cleaning and plaque control may be performed during any trimester

• The best time to address active dental disease (cavities, etc.) during pregnancy is during the 2nd trimester and early part of the 3rd trimester • In the 3rd trimester, the dentist should not perform any elective procedures except emergency dental care

• Always protect the patient and fetus by using a lead apron when making radiographs • Avoid prescribing medications that are considered a risk by the FDA (see the

following table)

• When using a local anesthetic, use one with a vasoconstrictor • Avoid nitrous oxide during the first trimester • Can use Chlorhexidine throughout pregnancy

CATEGORIES OF RISK FOR DRUGS DURING PREGNANCY Category Description A B C
These drugs are the safest. Well-designed studies in people show no risks to the fetus Studies in animals show no risk to the fetus, and no well-designed studies in people have been done. In animal studies, use of the drug resulted in harm to the fetus, but no information about how the drug affects the human fetus is available. Evidence shows a risk to the human fetus, but benefits of the drug may outweigh risks in certain situations. Risk to the fetus has been proved to outweigh any possible benefit.

D X

Infective endocarditis

Pathogenesis of IE
• Endothelial damage. • Non-bacterial thrombotic endocarditis(NBTE) • Bacteremia (source??) • Bacterial colonization of vegetation • Additional deposition and growth of thrombus • Embolization and bacteremia

Most Common Pathogens
• Staphylococci account for the majority of device-related infections
– Coagulase-negative staphylococci – Staphylococcus aureus

• A minority of infections are caused by:
– Other Gram-negative cocci – Gram-negative bacilli – Fungi (e.g. Candida spp.)

A o rti va l e n d o ca rd i s c ve ti

Signs and Symptoms of IE
• Nonspecific: low grade fever, heart murmur, night sweats, fatigue. • Stroke, MI, blindness, abdominal pain, petechiae, Osler nodes, splinter hemorrhages, Janeway lesions.

IE Mortality Rates
• 100% fatal if not treated • With antibiotic treatment, fatality rate:
– NVE (native valve) • Streptococcus <10% • Staphylococcus 25-40% • Gram negatives 75-83% • Fungi 50-60% – Late PVE (prosthetic valve) 30-53%

Dental Procedures and IE: Conventional Wisdom
• Dental procedures are a source of bacteremias. • Viridans streptococci (normal oral flora) account for many cases of BE, therefore, dental procedures are the source of these bacteria. • Antibiotic prophylaxis will prevent the development of endocarditis if given prior to dental procedures to prevent infective endocarditis.

Prevention of Infective Endocarditis

Cardiac Conditions with the Highest Risk of Endocarditis for Which Prophylaxis with Dental Procedures is Recommended
• Prosthetic cardiac valve • Previous infective endocarditis • Congenital heart disease (CHD) except for the following: – Unrepaired cyanotic CHD. – Completely repaired CHD with prosthetic material or device . – Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device which inhibits endothelialization • Cardiac transplantation recipients who develop cardiac valvulopathy

Congenital Cyanotic Heart Disease

Congenital Heart Defects That Cause Cyanosis
Tetrology of Fallot Transposition of the great arteries Persistent truncus arteriosis Tricuspid atresia Pulmonary atresia Totally anomalous pulmonary venous connection • Hypoplastic left heart syndrome • • • • • •

Conditions for which prophylaxis is no longer recommended • Mitral valve prolapse with regurgitation • Rheumatic heart disease and other types of acquired valvular heart disease (e.g. SLE) • Ventricular septal defect • Atrial septal defect • Hypertrophic cardiomyopathy

Dental Procedures for Which Endocarditis Prophylaxis is Recommended • All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
• Except the following:
– Routine anesthetic injections through noninfected tissue – Taking dental radiographs – Placement of removable prosthodontic or orthodontic appliances – Adjustment of orthodontic appliances – Shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa

Situation Oral

Regimens for a Dental Procedure Agent Regimen-Single dose 30-60
Amoxicillin minutes before procedure Adults Children 2 gm 50 mg/kg 2 gm IM or IV 50 mg/kg IM 1 gm IM or IV or IV 2 gm 600 mg 500 mg 500 mg 50 mg/kg 20 mg/kg 15 mg/kg 15 mg/kg

Unable to take Ampicillin or oral medication cephazolin or cephtriaxone Allergic to Cephalexin* or penicillin or Clindamycin or ampicillin Azithromycin or Oral Clarithromycin Allergic to penicillins or ampicillin and unable to take oral medication Cephazolinn or cephtriaxone Clindamycin phosphate

1 gm IM or IV 50 mg/kg IM 600 mg IM or IV or IV 20 mg/kg IM or IV

Whoops! You forgot to give the patient the antibiotic. What now?
• If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. However, the administration of the dosage after the procedure should be considered

only when the patient did not
receive the pre-procedure dose.

For patients already taking penicillin or amoxicillin (e.g. prevention of acute rheumatic fever, treatment of sinusitis)
• In such cases , due to the likelihood of the presence of penicillinresistant bacteria in the oral flora, the provider should select either clindamycin, azithromycin, or clarithromycin for IE prophylaxis for a dental procedure

Nonvalvular Cardiovascular Device-Related Infections
• Intracardiac:
– – – – – – – – – Pacemakers Defibrillators LVADs Ventriculoatrial shunts Pledgets PDA occlusion devices ASD and VSD closure devices Conduits Patches

• Arterial:
– Peripheral vascular stents – Vascular grafts, including hemodialysis – Intra-aortic balloon pumps – Coronary artery stents – Patches

• Venous:
– Vena cava filters

Guidelines
• At present, there is no convincing evidence that microorganisms associated with [dental] procedures cause infection in nonvalvular cardiovascular devices at any time after implantation. So that it is not recommend to give antibiotic prophylaxis.
– Prophylaxis is recommended for patients when they undergo incision and drainage of infection (e.g. abscess)

References
• Donald Falace ,Infective Endocarditis Prophylaxis (An Update on the New American Heart Association Guidelines), April 19,2007. • S J Davies & R M J Gray, The examination and recording of the occlusion: why and how, British Dental Journal 191, 291 - 302 (2001). • Richard Rathe, Examination of the Head and Neck, Copyright: 1996 by the University of Florida. • Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St. Louis, MO: Mosby Year Book, Inc; 1993: 341-360. • Linda Russell RDH, PhD, CHES  Source: Journal of Dental Hygiene    2004;78(3):3  Publisher: American Dental Hygienists' Association. • Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St Louis, MO: Mosby Year Book, Inc; 1993: 248-257. • Dr. Jin Y. Kim, Management of Hypertension in Clinical Dentistry. •   Donald A. Falace, Dental Management of Patients

My message • I made this presentation for all general dentists to benefit the practice of dentistry all over the word, and to save the life and the quality of life for our patients.

 Say no to drugs 

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