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Dental management of medically compromized patients

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  • 1. Dental Management of Medially Compromised (Patients (1 Dr. Usama M. Madany Prof. Oral Medicine, Periodontology, Diagnosis and Oral Radiology, Faculty of Dental Medicine, Al- Azhar .Univer. , Cairo, Egypt
  • 2. Hemolytic Anemias Sickle cell disease (Sickle cell anemia (homozygous (Sickle cell trait (heterozygous Thalassemia Alpha thalssemia Beta thalssemia (Thalsssemia major (homozygous thalassemi, Cooley’s anemia (Thalssemia minor (heterozygous thalassemia, thlassemia trait Glucose 6 Phosphate Dehydrogenase Deficiency (G6PDD, Favism(
  • 3. Sickle cell anemia is an inherited blood disorder caused by structurally abnormal haemoglobin (Hb S ( that causes a rigid distorted red blood cell (sickle cell( Acute crises may occur spontaneously or precipitated by Infection Dehydration Increased viscosity and clumping of RBCs Thrombosis Ischemia Infarction Hypoxia Sedatives and local anaesthetics Cold Hemolytic Anemia Weakness Splenomegaly Heart failure
  • 4. Dental Aspects Oral Manifestations Pale and yellow oral mucosa -Maxillary overgrowth - -Delayed eruption -Enamel hypoplasia Radiographic findings
  • 5. Hair on End appearance
  • 6. Problems •Susceptibility to infection •Susceptibility to develop crisis •Bleeding tendency
  • 7. Dental considerations and management Never Anesthetize or operate on patients during crisis (except for the relief of pain and treatment of infection). Use tourniquet Use GA in the clinic (GA must be carried out in a hospital with full anesthesia facilities and in close cooperation with a hematologist) Prescribe drugs that can cause respiratory depression and hypoxia such as sedatives (Nitrous oxide can be used safely as long as oxygen conc. is <50%).
  • 8. Expect Cerebral or cardiac hypoxia my result in these patients with minor procedure Poor wound healing after minor surgery or extraction Pulpal symptoms are common without obvious dental disease Infarction of bone may result in osteomyelitis esp. in the mandible
  • 9. Remember -Patient’s physician should be consulted about the patients myocardial status. -Preventive dental care is important. -Dental infections should be treated vigorously, if facial cellulitis develops patient should be admitted to the hospital. -Pain medications for patients with sickle cell disease include paracetamol, paracetamol with Codeine, NSAID’s and narcotics especially morphine. However, the use of Meperidine (Demerol) should be avoided as much as possible since one of its toxic metabolites (normeperidine) has a long plasma half-life and can cause seizures.
  • 10. -Due to high risk of infection in such patients, prophylactic antibiotic regimen for prevention of endocarditis should be followed before any dental procedures that can cause transient bacteremia. -After surgical procedures, antibiotics ( 500 mg penicillin VK 4 times/day or erythromycin, 250 mg 4 times/day, for penicillin-allergic patients) should be continued for 7-10 days postoperatively. -Use of vasoconstrictor in local anesthesia is controversial, however, for short routine procedures lacking discomfort , the vasoconstrictor should not be used. If the procedure requires long profound anesthesia, 2% lidocaine with 1/100,000 adrenaline is the anesthetic of choice.
  • 11. If general anesthesia is required, it is advisable to carry out comprehensive dental treatment, including any extraction or restoration that may be required, so as to avoid a second procedure.
  • 12. Trait of hemoglobin is HbS 60%Patient is asymptomatic and lives normal life Sickle cell crisis can be precipitated by reduce oxygen tension Few problems in managementGeneral anesthesia better be performed in hospital * with full oxygen supply Acute infections should be treated immediately* Prophylactic antibiotic cover before surgery*
  • 13. Thalassemia Group of congenital disorders characterized by deficient synthesis of either α or β chains of .hemoglobin in Hb Alpha thalssemia Imbalance in globin chain chains in RBCs + hemolysis Beta thalassemia precipitation of these ineffective erythropoiesis
  • 14. Beta thalassemia Homozygous thalassemia (Cooly’s anemia) no or few normal-1 beta chains Heterozygus thalassemia-2 Cooley’s anemia Oral manifestations Pale or/and oral mucosa Painful swelling of salivary glands Painful tongue Large head and mongoloid characters Teeth discoloration Enlargement of premaxilla Hyperplasia of bone marrow Spacing of upper ant. teeth Delayed sinuses’ pneumatization
  • 15. a b
  • 16. Dental implications Expect poor wound healing- 1 Antibiotic is required to control infection without delay- 2 .Avoid GA in dental clinic- 3 .Avoid excessive bleeding during surgery- 3
  • 17. Glucose 6 Phosphate Dehydrogenase )Deficiency (G6PDD Erythrocyte metabolic defect characterized by hemolysis due to .denaturing of hemoglobin in presence of oxidant compounds Life span of RBCs is 2/3 the normal and this is compensated by liver and bone marrow Diabetes Infection Oxidants compounds Hemolysis General anesthesia Dental management Avoid oxidant drugs eg asprin, phenacetin, sulphonamides,- 1 chloramphenicol, and vit .K Infection should be treated without delay-2
  • 18. Renal Disorders • Chronic renal failure/hemodialysis. • Renal transplantation.
  • 19. Renal Disorders Problems • Increased susceptibility to infection + immunosuppression •Bleeding tendency. •Decreased ability to excrete drugs. •Existence of A-V shunt. •Cross infection.
  • 20. Dental Aspects and management Chronic renal failure It is generally preferable to treat patients before rather than after dialysis or transplantation 1-Consult patient’s physician 2-Monitor blood pressure 3-Check lab values, PTT, PT, platelet count, bleeding time, blood urea nitrogen (do not treat if less than 60 mg/100ml) and serum creatinine (do not treat if less than1.5 mg/100ml). 4. If medical parameters permits Eliminate all foci of infection Keep only the easily maintainable teeth Try to keep good oral hygiene
  • 21. Normal Lab Values Normal Comfort Zone PT PTT 12-14sec 1.5x normal 25-35sec 1.5xnormal Platelets 150,000-450,000 Min 50,000 Hemoglobin Males: 13.5-17.5 g/dL 10g/dL Hematocrit Females: 12-16 g/dL Males: 39-49% BT min 3-9 30% Females: 35-45% 1.5x normal
  • 22. Avoid prescribing- 5 Tetracyclines, streptomycin, Vancomycin, Gentamycin. Acyclovir acetaminophen, phenacetine, NSAIDs, asprin, antihistamines, phenobarbitones Decrease dose of Cephalosporins, penicillins,, ampicillin, metronidazole, acyclovir, paracetamol, benzodiazpine Normal dose Cloxacillin, erythromycin, minocycline, codiene, diazepam, lidocaine
  • 23. Hemodialysis High incidence of serum hepatitis High incidence of anemia Significant incidence of secondary hyperparthyroidism Uremic stomatitis may exist Undergo heparinization during hemodialysis Have arteriovenous shunt or fistula a
  • 24. Dental management Screen for HBsAg and HBsAb-1 Antibiotic prophylaxis to prevent endartritis of-2 arteriovenous fistula Prevent hypoxia-3 Provide treatment on the day after hemodyalisis-4 5-Be careful to protect the fistula or shunt when patient on dental chair 6-Refer the patient to physician if uremic stomatitis is noted to develop
  • 25. Renal transplant patient Infection in such patients is life –threatening Before transplantation easily only maintained teeth should be determined by dental team approach Teeth with furcation involvement, periodontal abscesses, or extensive surgical requirements should be extracted Management Emergency tx only for 1st 6 months- 1 HBsAg screening- 2 3-Prophylactic antibiotics according to AHA recommendations 4- Erythromycin is contraindicated in patients on cyclosporins 5Immunosuppressed pt requires supplemental corticosteroids