ceramah 1Common Med Probs in Dentistry Part 1.pptx

medical problem

1. Common Medical Problems in Dentistry Dr. Harvinder Singh Dhillon​ (BDS, MOMFS, MFDS, FRACDS)

2. Content Cardiovascular system Infective endocarditis Hypertension Ischemic Heart Disease  Cardiac arrythmias  Congestive Heart Failure Hematology & bleeding disorders Disorders of RBC e.g., anemia Disorders of WBC e.g., leukemia Anti-thrombotic agents Respiratory system Asthma Chronic Obstructive Airway Disease Common Medical problems in Dentistry 2

3. Cardiovascular System 3

4. Risk Assessment for Cardiac Conditions – Identify the cardiac problem History - any cardiovascular disease? If yes, ask for details…what treatment, where treatment … what medication …  Recent chest pain? On anti-coagulants? On any GTN ( ubat letak   bawah lidah , botol kaca gelap ) ? If Yes, ask for details… compliant?  When was the last attack if any?

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6. Infective endocarditis

7. Infective Endocarditis 7

8. Infective Endocarditis Procedural risks for bacteraemia in IE Understand… that IE may occur due to reasons OTHER than your dental procedures

9. Infective Endocarditis Antibiotic Prophylaxis Only for the highest risk group For procedures that involve manipulation of gingiva or periapical region, and perforation of oral mucosa Not required for : L.A., prosthetic tx , orthodontic tx , radiographs, shedding of primary teeth AHA guideline updated 2021 with scientific statement

10. Infective Endocarditis Prosthetic cardiac valves , including transcatheter-implanted prostheses and homograft. Prosthetic material used for heart valve repair, such as annuloplasty rings, chords or clips. Previous IE . Unrepaired cyanotic congenital heart defect (birth defects with oxygen levels lower than normal), or repaired congenital heart defect, with residual defects Cardiac transplant with valve regurgitation due to a structurally abnormal valve. AHA guideline updated 2021 with scientific statement

11. Infective Endocarditis AHA guideline updated 2021 with scientific statement

12. hypertension

13. Hypertension Abnormal elevation of arterial pressure Sustained elevated systolic blood pressure of >140mm Hg or diastolic > 90mm Hg Classified into : primary, secondary

14. Hypertension

15. Hypertension Problems/Concerns for hypertensive patients: Sudden acute elevation of BP  stroke or MI Bleeding from procedural sites/extraction sockets Risk assessment BP control (careful with non-compliance) Difficulty & duration of procedure Additional risks (on anti-coagulants, ESRF on dialysis) White coat hypertension?

16. Hypertension Dental Management: Check BP Schedule patients mid morning For < 60 yrs : <140/90 For > 60 yrs : <150/90 Careful use of L.A. with vasoconstrictor ; when giving IA block. Generally 1-2 cartridges of 2% Lidocaine with 1:100,000 epinephrine is safe (similar to mepivacaine ) Avoid rapid change in chair position; to avoid drug induced orthostatic hypotension Avoid gingival retraction cords/ use adrenaline free GRC

17. IHD Due to atherosclerosis (thickening of the inner wall of vessels, by accumulation of lipid plaques) of the coronary arteries of the heart. Ischemic symptoms are the result of oxygen deprivation secondary to reduced blood flow to a portion of the myocardium

18. IHD (1.) Stable Angina vs (2.) Unstable Angina vs (3.) Myocardial Infarction Stable - chest pain is characteristically by a consistent, recurring, and unchanging pattern brought on by exertion or stress that typically subsides within 5 to 15 minutes with rest or use of nitroglycerin Unstable - worsening chest pain with a pattern of increasing severity, frequency, or duration. Pain can occur at rest!  MI - pain is unremitting after 15 minutes

19. IHD Dental Management: Risk assessment Procedural / magnitude of dental treatment Additional risks: e.g. old age + DM + ESRF + history of heart failure + recent ischemic event Some patients have been treated with CABG or stent(s), and they compliant to diet control & medication… and are asymptomatic!

20. IHD Dental MX: Adequate pain control but avoid NSAIDS (especially if patients already on anticoagulants) Limit L.A. with vasoconstrictors (~2 cartridges) Avoid gingival retraction cords with epinephrine Have GTN chairside during treatment

21. IHD Dental MX: Patient with IHD, stents, CABG(bypass) DO NOT require antibiotic prophylaxis Postpone all elective dental treatment if patient had/has MI or unstable angina in the past 30 days – refer/consult physician. Consider deferment until ~6 months or refer to specialist care for emergency treatment. DO NOT stop any medications/dose modification Patients on warfarin; INR <3.5; stable & within his/her therapeutic range. Last reading within 24-72 hrs

22. Cardiac Arrythmias

23. Cardiac Arrythmias Any variation in the normal heartbeat ,includes disturbances in rhythm , rate , or the conduction pattern of the heart. Tachycardia Bradycardia Fibrillation 

24. Cardiac Arrythmias Common medications used for treatment & their oral manifestations: Beta-blockers: propranolol, atenolol (taste changes, lichenoid reactions) Potassium channel blockers: Amiodarone (taste changes) Calcium channel blockers: Verapamil (gingival hyperplasia) Others: Digoxin (hypersalivation), warfarin (bleeding gums) Novel Oral AntiCoagulants [NOAC] : Dabigatran, Rivaroxaban, Apixaban (bleeding gums)

25. Congestive Heart failure

26. Heart Failure Defined as a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood …‘pump rosak ’…(or inefficient)

27. Heart Failure

28. Cardiac Arrythmias & Heart Failure Dental Management: Adequate analgesia (avoid NSAIDS) Stress management Limit L.A. (~2 cartridges) NO need for prophylactic Antibiotics Careful with use of metronidazole in patients with Warfarin, could increase INR INR should be within therapeutic range, < 3.5, last reading within 72 hrs; readings should be consistent – indicating compliance to medication & diet

29. Cardiac Arrythmias & Heart Failure Dental Management: No need for dose modifications for patients on oral anticoagulants/NOAC’s Use of local haemostatic measures Avoid electrosurgery/electrocautery for patients with pacemakers Some heart failure patients may not tolerate supine position due to pulmonary congestion If in doubt, consult a physician/specialist dental clinic. Treatment may be best performed in a hospital setting !

30. Cardiac Arrythmias Pacemakers & potential electromagnetic interferences: MRI Electrosurgery TENS Radiotherapy  Neurostimulators/defibrillators  **although modern cardiac devices are SHIELDED, some ( magnetostrictive ) ultrasonic scalers & apex locators can interfere with (older) cardiac devices

31. Hematological Disorders

32. Disorders of Red Blood Cell’s Iron Deficiency Anemia Folate Def. Anemia B12 Def. Anemia/Pernicious Haemolytic Anemia Sickle Cell Anemia G6PD Def. Aplastic Anemia Thalassemia Alpha/Beta; Minor/Major

33. pallor

34. Dental Management Risk & safety assessment; Hb levels > 10g/dL, & symptom free , good O2 saturation, normal BP & HR  Patients with most Anaemias, G6PD, Thalassemia minor can be safely treated at primary care G6PD; -Sensitivity with Sulfa based drugs, aspirin (high dose), chloramphenicol, penicillin, streptomycin, isoniazid… … ,resulting in haemolysis -Dental infections can precipitate haemolysis Safe to give PCM, NSAIDs in small therapeutic doses

35. Dental Management Risk & safety assessment; Aplastic Anaemia patients are prone to bleeding & infections; best treated in hospital setting Careful with Thalassemia Major patients ( s&s are more severe)

36. Disorders of White Blood Cells

37. Disorders of WBC Best managed in specialist centers

38. Anti Thrombotic Agents

39. Dental Mx of patients on Warfarin Increased risk of prolonged bleeding if INR >3.5, DO Not proceed with procedures where bleeding might occur Latest reading within 24-72 hrs Refer or consult a specialist centre/physician if in doubt More importantly…. for the INR to be stable & within the therapeutic range intended Careful during administration of L.A. ; aspirate. Risk of hematoma formation, deep tissue bleeding

40. Dental Mx of patients on Warfarin For cases where prolonged bleeding is anticipated; may bridge to heparin in a hospital setting Use local haemostatic measures Drugs to avoid: Avoid Aspirin & other NSAIDS – prolong bleeding Metronidazole & Macrolides (erythromycin) can potentiate effects of warfarin some herbal medications & food (spinach, broccoli) can interact/potentiate Warfarin.

41. Dental MX of patients on other anti-thrombotic agents Risk assessment , consult physician/specialist Additional considerations: Single, Dual or Triple antiplatelet therapy Procedural risks i.e. difficult surgery Pyogenic/inflammatory lesions Individual risks i.e. alcoholism For simple procedures proceed as usual, do not stop any of the medications

42. Other congenital bleeding disorders Best managed in a hospital setting

43. Local hemostatic Measures

44. Respiratory Disorders

45. Classification of Respiratory Disorders Obstructive conditions (e.g., emphysema, bronchitis, asthma attacks) Restrictive conditions (e.g., cystic fibrosis, sarcoidosis, alveolar damage, pleural effusion) Vascular diseases (e.g., pulmonary edema , pulmonary embolism, pulmonary hypertension) Infectious, environmental and others (e.g., pneumonia, tuberculosis, asbestosis, particulate pollutants)

46. Asthma

47. Asthma History of asthma, frequency of attacks, nocturnal coughing, shortness of breath, chest tightness, dyspnea on exertion. Well controlled? Steroid use? Hx of recent visits to A&E?

48. Inhalers

49. Dental Mx Risk assessment Prevention/ manage stress, anxiety/ air-conditioning Postpone dental Tx for severe & uncontrolled asthma Advise patients to bring their inhalers; consider prophylactic inhalation prior to surgery Avoid NSAIDS, Aspirin Dose adjustment for long term steroid users, risk assessment *LA with sulphites

50. Chronic obstructive airway disease

51. Chronic Obstructive Airway/ Pulmonary Disease Lung diseases characterized by loss of lung tissue and its surface area Chronic bronchitis, emphysema Commonly affecting >40 yrs Most common cause: smoking

52. ‘Blue Bloaters’ & ‘Pink Puffers’

53. Dental Mx

54. Thank you Any Questions?