Medically compromised 1


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Medically compromised 1

  1. 1. Medically compromised Patient Islam Kassem
  2. 2. 1- Cardiovascular problems2-Pulmonary problems3-Renal problems4-Hepatic disorders5-Endocrine disorders6-Hematologic problems7-neurologic disorders8-Manaement of pregnant & postpartum patients
  3. 3. 1st lecture1- Cardiovascular problems2-Pulmonary problems3-Renal problems4-Hepatic disorders
  4. 4. 2nd Lecture5-Endocrine disorders.6-Hematologic problems.7-neurologic disorders.8-Manaement of pregnant & postpartum patients.
  5. 5. 1- Cardiovascular problems• Ischemic heart disease• Cerebrovascular Accident (stroke)• Dysrhythias• Infective endocarditis• Congestive heart failure
  6. 6. Ischaemic Heart Disease Clinical Aspects For DENTIST
  7. 7. Coronary Artery DiseaseA leading cause of SICKNESS and DEATH
  8. 8. Coronary Heart Disease: Myocardial Ischemia• An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia.• Decreased blood supply (and thus oxygen) to the myocardium that can result in acute coronary syndromes: – Angina pectoris ( Stable ) – Unstable Angina – Myocardial infarction – Sudden death (due to fatal arrhythmias)
  9. 9. Ischaemic heart disease Aetiology• Fixed – Age, Male, +ve family history• Modifiable – strong association – Dyslipidaemia, smoking, diabetes mellitus, obesity, hypertension• Modifiable - weak association – Lack of exercise, high alcohol consumption, type A personality, Oral Contraceptive Pills, soft water –PRIMARY PREVENTION Atherosclerosis
  10. 10. Non-Modifiable Risk Factor: SEX
  11. 11. Non-Modifiable Risk Factor: AGE
  12. 12. Non-Modifiable Risk Factor: FAMILY HISTORY
  13. 13. Modifiable Risk Factor: DIABETES
  14. 14. Modifiable Risk Factor: SMOKING
  15. 15. Modifiable Risk Factor: OBESITY
  16. 16. Modifiable Risk Factor: DYSLIPIDEMIA
  17. 17. Ischaemic heart disease Manifestations• Sudden death• Acute coronary syndrome ( Myocardial Infarction & Unstable Angina )• Stable angina pectoris• Heart failure• Arrhythmia• Asymptomatic
  18. 18. Angina Pectoris• At least 70% occlusion of coronary artery resulting in pain. – Chest pain• - Characteristics: squeezing, bursting, pressing, burning or choking - Location: substernum - Refer pain: L’t shoulder, arm, neck or mandible - Associated with exertion, anxiety - Relieved by vasodilator (ex. NTG) or rest - May accompanied by dyspnea, nausea& vomiting sensation, palpitation• Usually brought on by physical exertion• Is self limiting usually stops when exertion is ceased
  19. 19. Angina pectoris• Potential problem related to dental care 1. Stress and anxiety related to dental visit may precipitate angina attack• Prevention of complication 1. Detection of patient 2. Referral of patient for medical evaluation and treatment 3. Known case with medical treatment for angina – Stress reduction protocol • Premedication • Open and honest communication • Morning appointments • Short appointments • Nitrous oxide - oxygen – Avoid excessive amounts of epinephrine
  20. 20. 1. Terminate all procedures2.3. Semi-reclined position Sublingual NTG Angina Pectoris4. O25. Check vital signsDiscomfort relieved Still discomfort after 3min6. Assume angina pectoris was present Give 2nd NTG7. Slowly taper O2 over 5min8. Modify dental treatment Still discomfort after 3min Give 3rd NTG Still discomfort after 3min NTG 0.6mg/tab
  21. 21. 10. Assume myocardial infarction in progress11. On IV line12. Prepare transport to ER If highly suspected AMI MONA: Morphine, Oxygen, NTG, Aspirin
  22. 22. Myocardial Infarction• Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle• When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels
  23. 23. Chest Pain• Site Jaw to navel, retrosternal, left submammary• Radiation Left chest, left arm, jaw….mandible, teeth, palate• Quality/severity tightness, heaviness, compression…clenched fists• Precipitating/relieving factors physical exertion, cold windy weather, emotion rest, sublingual nitrates• Autonomic symptoms sweating, pallor, peripheral vasoconstriction, nausea and vomiting
  24. 24. Treatment• Stop dental treatment• Call for help• Rest, sit up and reassure patient• Oxygen• Analgesia (opiate, sublingual nitrate)• Aspirin• Thrombolysis• Primary angioplasty• Beta-Blockers• ACE inhibitors• Prepare for basic life support• Transport patient to hospital
  25. 25. Surgical Treatment• Percutaneous Transluminal Coronary Angioplasty (PTCA) – balloon expansion that can provide 90% dilitation of vessel lumen – Stent Placement• Coronary Artery By- Pass Graft (CABG)
  26. 26. Dental Considerations for IHD• Common Situations: – Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…) • Raise chair slowly • Allow patient to take his/her time • Assist patient in standing – Post-Op Bleeding: • When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation• Emergent Situations: – Possible MI: • Remember that pain in the jaw may be referred pain from the myocardium  assess the situation, have good patient history, follow ABC’s – Angina: • In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually
  27. 27. RISK FOR DENTAL PROCEDURE• Major Risk for Perioperative Procedures: – Unstable Angina (getting worse) – Recent MI• Intermediate Risk for Perioperative Procedures: – Stable Angina – History of MI• Most dental procedures, even surgical procedures fall within the risk of less than 1%• Some procedures fall within an intermediate risk of less than 5%• Highest risk procedures  those done under general anesthesia
  28. 28. Post MI: When to Treat• Why delay treatment? – Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patient’s daily life• MI within 1 month  Major Cardiac Risk• MI within longer then 1 month: – Stable  routine dental care ok – Unstable  treat as Major Cardiac Risk• Older studies suggest high re-infarction rates when surgery performed within 3 months, 3-6 months… however, this was abdominal and thoracic surgery under general anesthesia• New research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signs• When in doubt: – CONSULT THE CARDIOLOGIST
  29. 29. Dental Management: Stable Angina/Post-MI >4-6 weeks• Minimize time in waiting room• Short, morning appointments• Preop, intra-op, and post-op vital signs• Pre-medication as needed – anxiolytic (triazolam; oxazepam); night before and 1 hour before – Have nitroglycerin available – may consider using prophylacticaly• Use pulse oximeter to assure good breathing and oxygenation• Oxygen intraoperatively (if needed)• Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)• Avoid epinephrine in retraction cord
  30. 30. Dental Management: Unstable Angina or MI < 3 months• 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 needed
  31. 31. Warning Signs and Symptoms of Heart attack1) Pressure, fullness or a squeezing pain in the center of chest that lasts for more than a few minutes.2) Pain extending beyond the chest to the shoulder, arm, back or even your teeth and jaw.3) Increasing episodes of chest pain4) Prolonged pain in the upper abdomen5) Shortness of breath- may occur with or without chest discomfort6) Sweating7) Impending sense of doom8) Lightheadedness9) Fainting10) Nausea and vomiting
  32. 32. Conclusion:• When treating patients with Ischemic Heart Disease or recent MI… – Use caution and common sense – When in doubt: • CONSULT THE CARDIOLOGIST
  33. 33. Dental Management ofPatients with Heart Failure
  34. 34. Sequelae of Heart Failure• Right Heart • Left Heart Failure Failure – Systemic – Pulmonary venous edema congestion (Dyspnea) (distended neck veins, enlarged liver, peripheral edema, ascites)
  35. 35. Symptoms of Heart FailureCompensated (Asymptomatic)Uncompensated (Symptomatic)• Fatigue• Dyspnea• Orthopnea• Paroxysmal Nocturnal Dyspnea• Ankle Edema• Weight GainNote: patients with a very low EF may have no symptoms
  36. 36. Functional Classification of Heart Failure• Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity• Class II: Slight limitation of physical activity. Fatigue, palpitations and dyspnea with ordinary physical activity but comfortable at rest.• Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms but comfortable at rest.• Class IV: Symptoms present at rest and any physical activity exacerbates the symptoms
  37. 37. Dental Management Considerations (Heart Failure)• For undiagnosed pt with symptoms of HF: avoid elective care; refer to physician• For patients with diagnosed HF: – Class I (asymptomatic): routine care – Class II (mild symptoms with exertion): elective care OK and recommend consultation with physician – Class III or IV (symptoms with minimal activity or at rest): avoid elective care; if treatment necessary, manage in consultation with physician; consider referral to a special patient care setting; avoid use of vasoconstrictors
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  43. 43. 2-Pulmonary problems• Asthma• Chronic obstructive pulmonary disease
  44. 44. Asthma• Characterized by reversible airway obstruction and associated with a reduction in expiratory airflow – May be precipitated by allergens, pollution, exercise, stress, or upper respiratory tract infection – In status asthmaticus, patients have persistent life- threatening bronchospasm despite drug therapy – Signs of asthma include shortness of breath and wheezing
  45. 45. Chronic Obstructive Pulmonary Disease• Irreversible airway obstruction; occurs with either chronic bronchitis or emphysema – Chronic bronchitis is a result of chronic inflammation of the airways and excessive sputum production – Emphysema is characterized by alveolar destruction with airspace enlargement and airway collapse
  46. 46. Corticosteroids• Typical side effects seen with corticosteroid therapy do not occur with topical aerosol administration – Patients have a significant improvement in pulmonary function with a decrease in wheezing, tightness, and cough – Reduce inflammation, secretions and swelling in the lungs after an asthma attack• Prolonged inhalation may cause candidiasis
  47. 47. Dental Implications of the Respiratory Drugs• About 10% of the population has some form of pulmonary disease – With severe COPD, a person can develop pulmonary hypertension, increasing the risk for cardiac arrhythmias – Stress should be minimized and adrenal supplementation instituted if the patients are taking certain doses of steroids and the procedure is likely to produce severe stress
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  49. 49. 3-Renal problems• Renal faliure• Renal transplant & transplant of other organ• Hypertension
  50. 50. Anatomy• 2 Kidneys• 2 Ureters• Bladder• Urethra
  51. 51. Kidney Function• Detoxify blood• Increase calcium absorption – calcitriol• Stimulate RBC production – erythropoietin• Regulate blood pressure and electrolyte balance – renin
  52. 52. Symptoms of ARF• Decrease urine output (70%)• Edema, esp. lower extremity• Mental changes• Heart failure• Nausea, vomiting• Pruritus• Anemia• Tachypenic• Cool, pale, moist skin
  53. 53. Chronic Renal Failure Causes• Diabetic Nephropathy• Hypertension• Glomerulonephritis• HIV nephropathy• Reflux nephropathy in children• Polycystic kidney disease• Kidney infections & obstructions
  54. 54. Dialysis• ½ of patients with CRF eventually require dialysis• Diffuse harmful waste out of body• Control BP• Keep safe level of chemicals in body• 2 types – Hemodialysis – Peritoneal dialysis
  55. 55. Hemodialysis• 3-4 times a week• Takes 2-4 hours• Machine filters blood and returns it to body
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  58. 58. 4-Hepatic disorders
  59. 59. Hepatic Disorders Hepatic Insufficiency
  60. 60. Hepatic DisordersManagement of Patient with Hepatic Insufficiency1. Attempt to learn the cause of the liver problem; if the cause is hepatitis B, take usual precautions.2. Avoid drugs requiring hepatic metabolism or excretion; if their use is necessary, modify the dose.3. Screen patients w i t h severe liver disease for bleeding disorders with platelet count, prothrombin time, partial thromboplastin time, and Ivys bleeding time.4. Attempt to avoid situations in which the patient might swallow large amounts of blood.
  61. 61. Study source?
  62. 62. Contemprary Oral & maxillofacial surgeryPage 10-20
  63. 63. • You can get it form•