dental managenment of medically compromise patient

about oral surgery

1. D ental managements of medically compromised patients P resented by house surgeon Aung Zaw Moe Date – 13.6.2024 6/11/24 1

2. CONTENTS INTRODUCTION SYSTEMIC DISORDERS (that dentists should be aware of) MANAGEMENTS CONCLUSION REFRENCES 6/11/24 2

3. INTRODUCTION Medically compromised patients are those patients for dental treatment who are at risk on dental chair A n alert dentist should take all precautions needed before any dental procedures or dental surgery starts S ome systemic diseases or disorders may increase the risk accompained with a great complications that might me threatening patient’s life 6/11/24 3

4. S ystemic disorders B leeding disorders including anticoagulant medications C ardiac disease or defects hypertension D iabetes I nfectious diseases(T.B,HIV,and HEPATITIS ) 6/11/24 4

5. I mmuno-supressive and autoimmue disorders P regnancy L iver diseases K idney disorder L iver diseases C entralnervous system like seizured and strokes T hyroid disorders 6/11/24 5

6. M anagements of bleeding disorders I ncluding patients on anticoagulants; DIAGNOSTIC TESTS; B leeding problems secondary to liver diseases P rothrombin time (PT) P artial thrombin time(PTT) I nternational normalized ratio(INR) A sprin and anti inflammatry agents B leeding time(BT) 6/11/24 6

7. T hrombocytopenia CBC with differtial blood count B leeding time A nticoagulant warfarin PT INR 6/11/24 7

8. C hair side management and precautions during dental treatment NO treatment should be started; I f BT is greater than 10 minutes I f platelet count is less than 60000 I f PTT is greater than 45seconds I f PT is greater than 22 seconds I f INR is greater than 3.5 6/11/24 8

9. I f bleeding record are greater than above M edical consultion is needed D ecrease anticoagulant dose Vit.K adminstration A pply primary closure and (or) apply pressure over the bleeding site G eal foam may help to stop bleeding A void unnecessary procedures A ntibiotic adminstration to avoid super imposed infection and to promote healing 6/11/24 9

10. M anagement of cardiac and cardiovascular defects M edical consultation (high priority) to get safty for dental treatment P rophylatic antibiotic cover to avoid the risks of bacterial endocarditis(before,during,after) T reatment procedure (minimal invasive) R eduction of stress and anxiety(clonazepam 1mg) M anagement of complications (if)developed attack call an ambulance ,perform CPR 6/11/24 10

11. A ntibiotic regmens for prophylaxis of bacterial endocarditis Situation Agent Adults Children Oral Amoxillin 2g 50mg/kg Parenteral A mpicillin, Cefazolin,ceftriaxone 2g IM or IV 1g IM or IV 50mg/kg IM or IV 50mg/kg IM or IV P enecillin allergy (Oral) C ephalexin C lindamycin Azithromycin 2g 600mg 500mg 50mg/kg 20mg/kg 15mg/kg Penecillin allergy (Parentral) C efazolin Clindamycin 1g IM or IV 600mg IM or IV 50mg/kg IM or IV 20mg/kg IM or IV T otal children dose should not exceed adult dose 6/11/24 11

12. M anagement of patients with hypertension Proper medical history and M edical consultion M onitor BP (before,during and after)procedure P atient shoud take normal regmine for hypertension before procedure A xiety and stress reduction A ntibiotic cover U se LA without adrealine 6/11/24 12

13. DIABETES P ost surgical complications in case of uncontrolled diabetes constitute a real problem to dentist on chair side treatment for those patients B efore any invasive surgical treatment i.e surgical extrCation or prolong procedures,patients should be asked to show and prove that his or her blood sugar level is within the normal reading 6/11/24 13

14. D iagnostic test and precautions S trong medical and dental histry M edical consultation should be needed if F asting blood sugar level(N=less than 100mg/dl) R andom blood sugar level(N=less than 140mg/dl) P atient should have taken their medication before procedure A ntibiotic cover(if needed) 6/11/24 14

15. I nfectious diseases (T.B,HIV,HERPES AND FLU) D iagnostic test; T uberculosis(T.B); I f the test is postive,then chest X-ray is needed I f chest X-ray is postive or there is active infection,then T wo active sputum test for tuberculosis baccili(acid fast bacillus test) should be carried out to comfirm the disease 6/11/24 15

16. HEPATITIS I t is DNA virus that lives and mutiplies in hepatic cells.the virus is identified in the serum as three types of antigen, S urface antigen (s)HBsAg seen in serum 6 weeks after incubation peroid. C ore antigen(c )HBcAg-present in liver cells,not detected in serum E nvelope antigen( e)HBeAg-it indicate high infectivity and appear in acute condition. 6/11/24 16

17. TESTS C linical feactures and PCR and ELISA E levated liver enzymes; E levated prothrombin time,ESR S erologic tests;antigens and antibodies 6/11/24 17

18. HIV TESTS; V irus can be easily isolated from either blood and semen C urrent laboratory tests including T-cell count V iral isolation CBC,differential blood count for RBC,WBC,platelets count 6/11/24 18

19. HERPES/FLU; N o specific laboratory test needed V irus isolation(swab biopsy) 6/11/24 19

20. MANAGEMENT OF PATIENT WITH INFECTIOUS DISEASES (1) Under all circumstances medical consultation /and clearance should be obtained before any treatment starts, and / also no elective treatment should be carried out before physician says patient is on longer infectious (2) All precautions should be under taken if necessary treatment should be carried out 6/11/24 20

21. (3) in cases of HIV, Hepatitis, TB. and herpes, the normal universal precautions should be taken (4) Patients should be reappointed in cases of acute exacerbation and remission OR the patient are too weak to stands with the dental procedures OR when the patient should get back to his medications before any dental chair side treatment 6/11/24 21

22. MANAGEMENT OF PATIENTS WITH IMMUNOSUPPRESSIVE &AUTOIMMUNE DISEASES * Autoimmune, immunosuppressive and / also patient on immunosuppressive medications should have a restricted chair Side dental treatment to avoid risk factor specially in cases of HIV, leukemia, primary immunosuppressive diseases also cancer chemotherapeutic agents for patient having organ transplantation i.e liver / kidney and /or patients on corticosteroid hormones as a treatment for autoimmune disorders. 6/11/24 22

23. Precautions : *medical consultation *Aggressive and invasive dental procedures should be avoided *Proper /clean oral hygiene * antibiotic cover if needed *Prophylaxis for viral and fungal infection is considered *If there is low readings of blood count as concern WBC's ,RBC's and platelets count, patient should be reappointed 6/11/24 23

24. PREGNANCY * Management of pregnant women on dental chair: 1) First three months * NO dental treatment, NO dental x-rays, NO invasive or aggressive procedures * Emergencies ONLY, after Medical consultation to determine the suitable medication needed for the patient and /also a clearance is needed to confirm treatment to be started 6/11/24 24

25. (2) Second and first half of third trimester : *_ These are the appropriate and safest time for all desired dental treatment needed during pregnancy along with minimum drug use + medical clearance (3) Last half of third trimester : *NO dental treatment Except emergencies along with med. clearance and minimum drugs / trauma 6/11/24 25

26. Dental management for patients with liver disorders & patient on anticoagulant medications Tests needed : 1 ) Liver function tests 2 ) Prothrombin time (PT) 3 ) Partial thromboplastin time (PTT) 4 ) INR (international normalized ratio) 5 ) Bleeding time (BT) 6/11/24 26

27. Precautions (1) Medical clearance/consultation (2) Before all readings are back to normal ,NO dental treatment should be started (3) Avoidance of drugs that are toxic to the liver metabolization (4) Maintain high oral hygiene (5) Minimum surgical procedures 6/11/24 27

28. DENTAL MANAGEMENT OF PATIENTS W I T H KIDNEY DISORDERS Diagnostic tests : * BUN (blood, urea, and nitrogen) * Creatine clearance rate. Precautions : (1) Avoid drug toxicity / accumulation (2) Avoid invasive procedures to prevent poor and delayed healing (3) Avoid long chair side treatment for patient with kidney transplant /complications (4) Medical consultation / clearance (5) Prophylactic Antibiotic cover 6/11/24 28

29. M anagement of thyroid disorders M edical consitation M onitor vital signs before procedure T he use of epinephrine should be avoided P atient with hyperthyroidism usually have increased level of anxiety S tress and axiety reduction D ental treatment should be delayed if signs and symptoms of thyroid crisis develop,and emergency medical sevices should be in hand 6/11/24 29

30. CONCLUSION In deantal clinic,misreporting of underlying medical conditions can affect outcomes for dental patients A n accurate medical /dental history is vital since it may provide valuable information for the dentist prior to beginning treatment 6/11/24 30

31. REFRENCES Oral medicine lecture note(final year BDS) Contemporary Oral and Maxillofacial Surgery 7th Edition Malmed SF. Thyroid gland dysfunction in medical emergencies in the dental office 2000 St. Louis Mosby:275–86 5th ed 6/11/24 31

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