Management of medically compromised patients

Dr.Elhawary
Management of Medically compromised patients
Management Of Medically
Compromised Patients
Hesham El-Hawary
Associate Prof OMFS
www.elhawarydentalclinic.com

Dr.Elhawary
Importance
1. Recognition of existing medical condition
2. Adequate preparation
– Premedication
– Prophylaxis
– Adjustment
– Prepare for any adverse effects
3. Postoperative consideration to control
– Bleeding
– Infection

Dr.Elhawary
Patients Classification According to their physical condition
According to the American Society of Anesthesiologists (ASA)
Type I : Normal patient
Type II : Mild to moderate systemic disease
Type III: Sever systemic disease limiting patient activity
Type IV: Sever systemic disease threatening life
Type V : Morbid patient

Dr.Elhawary
Treatment options
1. Office treatment
• ASA type I
• ASA type II
2. Hospitalization
• ASA type III
3. Hospitalization and emergency treatment
only
• ASA type IV
4. Hospitalization and palliative treatment
• ASA type V

Dr.Elhawary
Stress Reduction Protocol
• Before appointment
1. Night before surgery
Sleeping bills (Valium 5-10 mg) optional
2. Day of surgery
Short acting barbiturates ( secobarbital 50 -100 mg ) optional
3. Early appointment
4. Short appointment

Dr.Elhawary
Stress Reduction Protocol cont.
• During appointment
1. Relaxing background music
2. Reassurance
3. No surprises
4. No unnecessary noise
5. Surgical instruments out of patient sight
6. Profound local anesthesia
7. IV sedation optional
8. Nitrous oxide sedation optional

Dr.Elhawary
Stress Reduction Protocol cont.
• After surgery
1. Further reassurance
2. Detailed information about expected postoperative
sequelae
3. Effective analgesics
4. Telephone call for the patient at home

Dr.Elhawary
CARDIOVASCULAR DISEASES
CARDIAC ARRHYTHMIAS
ANGINA PECTORIS
CORONARY ANGIOPLASTY
MYOCARDIAL INFARCTION
CORONARY ARTERY BYPASS GRAFTING
RHEUMATIC HEART DISEASE
HYPERTENSION
Management of patients with systemic diseases

Dr.Elhawary
CARDIAC ARRHYTHMIAS

Dr.Elhawary
• Condition:
1. Abnormal pulse rate or rhythm
2. Cardiac pacemaker
• Dental Management Considerations :
1. Consultation
2. Stress reduction protocol
3. Local anesthesia without vasoconstrictor (↑ arryhthmia)
4. Avoid diathermy and ultrasonic scaler in case of pacemaker
5. In case of decreased heart rate
→direct vigorous thumbing on the pericardium
6. In case of rapid heart beats
→ Vagal stimulation through carotid sinus massage

Dr.Elhawary
ANGINA PECTORIS

Dr.Elhawary
• Condition:
– Temporary inability of the coronary arteries to
supply the heart musculature by oxygenated blood
– Patient suffers from
• substernal pain radiates to the left shoulder
• Down to the fingers
• May radiate to the neck and jaws
– It always follows exercise, overeating, emotional
stress and cold weather and fear due to increased
levels of epinephrine and nor epinephrine
– If lasts more than 30 minutes → Myocardial
infarction

Dr.Elhawary
1. Consultation
2. Advise the patient to eat lightly before appointment
3. Premedication with short acting barbiturate
5. Nitroglycerine tablets sublingually
• 5 min before stressful procedure
• Keep it handy
6. Monitor vital signs
7. Avoid prolonged procedures
8. Avoid painful stimuli

Dr.Elhawary
• Dental Management Considerations: Cont.
– Injection of LA containing V.C.
IF NO V.C . → PAIN → endogenous adrenaline
 safe suggestion 2 carpules containing max
1:100.000 adrenaline
– Injection given very slowly + aspiration is a MUST
– In case of unstable angina postpone the regular
procedures, only emergency dental care should be
performed

Dr.Elhawary
CORONARY ANGIOPLASTY

Dr.Elhawary
• Condition:
Introduction of catheter containing balloon in
narrowed coronary arteries
– The same precautions for Angina pectoris
– Anticoagulant drug management
i. Never withdrawal of anticoagulants (rebound thrombosis )
ii. Reduce the dose of oral anticoagulant to maintain
prothrombin time 1.5 to 2 times the control
(e.g. 25 second normal 15 second)

Dr.Elhawary
MYOCARDIAL INFARCTION
CORONARY THROMBOSIS
(PATIENTS ON ANTICOAGULANTS)

Dr.Elhawary
• Condition :
– Anginal attack lasts more than 30 minutes
– Patient experiences sever substernal pain and may
go into shock and cardiac dysfunction that can lead
to death
• Clinical features:
– Prolonged anginal pain last more than 30 minutes
– Tachycardia and irregular pulse
– Nausea and vomiting
– Difficulty in breathing (pulmonary edema)
– Pallor with symptoms of shock

Dr.Elhawary
• Treatment:
1. Complete physical and mental rest
2. Morphine as pain killer
3. Anticoagulant therapy to diminish thromboembolic
complications
N.B. Penicillin antagonize the anticoagulant effect of
heparin
• Emergency treatment
1. Call emergency unit
2. CPR
3. Emergency oxygen
4. IM 10% lidocain
5. Nitroglcerin sublingually
6. IV thrombolytic agent injection (streptokinase)

Dr.Elhawary
1. Consultation and Advise hospitalization
2. Postpone elective surgery till after 6 months
3. Prophylactic coronary dilators
4. Anticoagulant drug management
i. Never withdrawal of anticoagulants ( fear of
rebound thrombosis )
ii. Reduce the dose of oral anticoagulant to maintain
prothrombin time 1.5 to 2 times the control
(e.g. 25 second normal 15 second)
6. Monitor vital signs

Dr.Elhawary
7. Decrease the amount of adrenaline
8. Local haemostatic measures
i. Constant pressure
ii. Gel foam in the socket after extraction
iii. Multiple sutures under tension
iv. Heavy bite pressure 1 hour at least
v. Ice Packs 1/2 hr on 1/2 hr off applied externally
9. Avoid mouth rinses and Hot liquids for 72 hrs

Dr.Elhawary
CORONARY ARTERY BYPASS GRAFTING

Dr.Elhawary
1. Postpone elective surgery till after 6 months
2. Same as myocardial infarction
3. For the first 6 months, patients may need
preoperative antibiotic prophylaxis against
infective endocarditis

Dr.Elhawary
RHEUMATIC HEART DISEASE

Dr.Elhawary
• Condition :
– Disease of altered immunological reaction to group A Beta-
hemolytic streptococcal infection
– The valves are frequently the site of subsequent Bacterial
Endocarditis (SBE)
– The most affected valves are the Mitral valve and the Aortic
valve subsequently
• Clinical features:
1. Septicemia
2. Petecheal haemorrhage
3. Finger clubbing – nail bed haemorrhage
4. Embolic complications in kidneys, brain, eyes
5. Cardiac failure

Dr.Elhawary
• Mortality rate:
– 100% without antibiotic treatment
– 10-65% for trerated patients
• Treatment :
– Prohylactic antibiotic against BE utilizing
– Cardiac surgery with prosthetic valve replacement

Dr.Elhawary
• Dental treatment consideration:
1. Careful history
2. Medical consultation
3. Adjusting the anticoagulant therapy
4. Antibiotic coverage
5. Antiseptic mouth wash
6. Local anesthesia with vasoconstrictor to minimize
bacteraemia
7. Atraumatic dental procedure
8. Two weeks is the minimum Interval between
sessions

Dr.Elhawary
• Antibiotic regimen
– Standard routine
• Amoxycillin 2 grams orally 1 hour before procedure
• For children 50 mg/kg orally 1 hour before procedure
– Unable to take oral medications
• Ampicillin 2 grams (IV/IM) 30 minutes before procedures
• For children 50 mg/kg (IV/IM) 30 minutes before
procedures

Dr.Elhawary
• Antibiotic regimen cont.
– Allergic to penicillin
• Clindamycin 600 mg orally1 hour before the procedures
• For Children 20 mg/kg orally 1 hour before the
procedures
– Allergic to penicillin and unable to take oral medication
• Clindamycin 600 mg (IM/IV)30 minutes before the
procedures
• For Children 20 mg/kg orally 1 hour before the
procedures

Dr.Elhawary
HYPERTENSION
Management of patients with systemic disease

Dr.Elhawary
• Condition:
1. The sum of COP, Blood volume, blood viscosity and vessel
elasticity
2. It is related to cardiovascular diseases, renal diseases and
atherosclerosis
3. Early signs:
i. Breathlessness
ii. Spontaneous nose bleeding
iii. Persistent headache
iv. Occular complaints
v. General malaise and dizziness
vi. Odontalgia with no local causes due to pulp hyperemia

Dr.Elhawary
• Classification of Hypertension
According to etiology
• Primary hypertension
(Idiopathic)
• Secondary hypertension
– Renal disease
– Adrenal cortical hyperfunction
– CNS lesion
According to its severity
• Normal blood pressure
120-140/85-90
• Mild hypertension
140-160/90-105 mmhg
• Moderate hypertension
160-200/105-114 mmhg
• Sever hypertension
>200/115 mmhg

Dr.Elhawary
• Complications:
– Patients with undetected hypertension may account
for occasional sudden death
– Due to elevation of the blood pressure that leads to
 Cerebral hemorhage
 Myocardial infarction
 Renal failure
 Heart failure

Dr.Elhawary
• Dental Management Considerations:
A. Mild to moderate hypertension:
1. Consultation
3. Monitor blood pressure
4. Decrease the amount of adrenaline (LA + VC (1/100,000))
5. Inject anesthesia slowly and avoid intravascular injection
6. local haemostatic measures carefully taken to avoid
undue hemorrhage
7. Avoid rapid posture changes that can leads to Orthostatic
hypotension and syncope

Dr.Elhawary
B. Severe hypertension >200/115
1. Consultation
2. Postpone till blood pressure is controlled
3. On emergency basis hospitalization
4. Premedication
5. Decrease the amount of adrenaline (LA + VC (1/200,000))
6. local haemostatic measures carefully taken to avoid
undue hemorrhage

Dr.Elhawary
HEMATOLOGIC DISEASE
DISEASES OF RBCS
ANEMIA
DISEASES OF WBCS
LEUKEMIA
HEMORRHAGIC DISEASES
HAEMOPHILIA

Dr.Elhawary
BLOOD DYSCRASIAS
RBCS DISORDERS
ANEMIA

Dr.Elhawary
• Definitions
• Anemia
– Deficient RBCs production
– Decreased RBCs count
– Decreased hemoglobin level
• Complications
– Not withstand blood loss
• Heart failure
• Myocardial infarction
– Postoperative hemorrhage
– Sore tongue

Dr.Elhawary
• Dental management consideration
2. Complete blood picture
3. Postpone surgery if hg concentration is less than 10g/100ml
4. Search for the signs and symptoms of anaemia
• sore tongue
• necrotizing ulceration of the gingiva
• bleeding during examination
5. Consider iron and multivitamin therapy preoperatively to
increase haemoglobin synthesis
6. Local haemostatic measures and prophylactic antibiotic
therapy to prevent postoperative infection should be
provided

Dr.Elhawary
BLOOD DYSCRASIAS
WBCS DISORDERS
LEUKEMIA

Dr.Elhawary
• Conditions
Progressive overproduction of immature WBCs in the blood
• Features
1. Gingival bleeding
2. Ulceration of oral mucosa

Dr.Elhawary
• Dental management consideration
2. Complete blood picture
3. Hospitalization
4. Search for the signs and symptoms of WBC disorders
5. Withdraw any systemic drug cause the condition
6. In cases need prolonged antibiotics periodic check-up by
blood picture is a must
7. Extraction is contraindicated unless under strict conditions
8. Local haemostatic measures and prophylactic antibiotic
therapy to prevent postoperative infection should be
provided

Dr.Elhawary
BLOOD DYSCRASIAS
HEMATOLOGIC DISEASES
HAEMOPHILIA

Dr.Elhawary
Disease involving blood factors
1. Haemophilia
– Haemophilia A (factor VIII)
– Haemophilia B (Christmas disease factor IX)
– Haemophilia C (plasma thromboplastin antecedent deficiency)
2. Pseudohaemophilia (factor VII)
3. Parahaemophilia (factor V)
4. Hypofibrinogenamia (factor I)
5. Hypoprothrombinaemia (prothrombin factor II)

Dr.Elhawary
• DENTAL MANAGEMENT CONSIDERATIONS:
1. Consultation
2. Laboratory investigations
Pt, ptt, INR, platelet count and bleeding time
3. Hospitalization
4. Replacement of the deficient factor or
platelet replacement (pre/post operatively)

Dr.Elhawary
5. Avoid nerve block techniques
6. Avoid major surgical procedures
7. Utilize atraumatic surgical protocol as possible
• Obliteration of the dental socket with absorbable
haemostatic materials
– Gel foam soaked with thrombin/fibrinogen
– Oxidized cellulose
• Using cryotherapy or electrocoagulation
• Suturing of the mucosa
• Application of astringents

Dr.Elhawary
9. Careful postoperative instruction
10.Postoperative blood transfusion
11.No NSAIDs
12.High infection control measures
13.Discharge the patient after 3 days without
bleeding

Dr.Elhawary
HEMATOLOGIC DISEASE
DISEASES OF RBCS
ANEMIA
DISEASES OF WBCS
LEUKEMIA
HEMORRHAGIC DISEASES
DISEASES INVOLVING PLATELETS
DISEASES INVOLVING BLOOD FACTORS

Dr.Elhawary
PULMONARY DISEASES
BRONCHIAL ASTHMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Dr.Elhawary
PULMONARY DISEASES
BRONCHIAL ASTHMA

Dr.Elhawary
• Condition:
– Spontaneous reversible spasmodic contraction of
the smooth muscles of the bronchioles
– Dyspnea, wheezing and cough
• Etiology :
1. Allergy
2. Viral infection
3. Familial

Dr.Elhawary
1. Consultation
3. Prophylaxis for adrenal insufficiency (under steroid)
4. Preoperative bronchodilators (Theophiline)
5. Oxygen
6. Patients on theophylline avoid prescribing:
Asprin, NSAIDs, Barbiturates, Narcotics, sulfite containing
preservative anesthetics, Erythromycine antibiotics
7. In more severe attack:
i. Aminophyline 250 mg IV very slowly
ii. Hydrocortisone 100 mg IV very slowly
iii. Oxygen

Dr.Elhawary
PULMONARY DISEASES
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE

Dr.Elhawary
• Condition:
– Bronchitis associated with excessive mucous
secretion, cough and expectoration
• Etiology :
1. Smoking
2. Environmental pollutants

Dr.Elhawary
1. Consultation
2. Schedule afternoon appointments to allow respiratory
clearance
4. Avoid premedication with narcotics or barbiturates as they
are respiratory depressants
5. Keep bronchodilator inhaler accessible
6. Place the patient in the dental chair in an upright position
7. Avoid bilateral palatal or mandibular nerve blocks to avoid
the sensation of respiratory obstruction

Dr.Elhawary
8. Use of rubber dam is not advised
9. Patients on oxygen, should be continued during surgery
10. Prophylaxis for adrenal insufficiency, if the patient is under
steroid treatment
11. Avoid antihistaminics & Atropine as they lead to dry mouth
and increase mucous production

Dr.Elhawary
ENDOCRINAL CONDITIONS
DIABETES MELLITUS
HYPERTHYROIDISM
ADRENAL INSUFFICIENCY

Dr.Elhawary
DIABETES MELLITUS

Dr.Elhawary
• Condition:
Chronic complex disease with metabolic and
vascular components
– Metabolic component:
Disorder in the metabolism of insulin,
carbohydrates, proteins and fats leads to elevation
of blood glucose level
– Vascular component
• Atherosclerosis
• Microangiopathy of small vessels

Dr.Elhawary
• Condition:
Susceptibility to infection may be due to:
1. Hyperglycemia
2. Vascular insufficiency
3. Ketoacidosis
4. Neuropathy
Normal Blood glucose level
Fasting < 125 mg/dl

Dr.Elhawary
• Diabetes is controlled by:
1. Diet
2. Diet & oral Hypoglycemic drugs
3. Diet & Insulin
N.B. patients controlled by diet and/or oral
hypoglycemics are non insulin dependant patients
(diabetes type II) while patients controlled by insulin
are the insulin dependant patients (Diabetes type I)

Dr.Elhawary
1. Consultation
Uncontrolled cases should be refereed for the physician
and only emergency treatment could be performed
3. Dental procedures are best performed in the morning
90 – 180 min after breakfast and insulin usual dose since it
is the hours of the descending part in blood sugar level
4. In non-insulin controlled patients all dental procedures
could be performed
5. Prophylactic antibiotic administration the day before & 2-3
days after surgery (in case of massive surgery)

Dr.Elhawary
6. Adjustment of the insulin dose preoperatively:
i. Normal postoperative feeding and Minimal surgical
intervention
→ do not change the dose
ii. Moderate surgical intervention that may affect the
postoperative feeding
→ Patient should take half the dose before surgery
iii. If the diet will be completely restricted postoperatively
→ Normal diet in the morning + No insulin intake

Dr.Elhawary
7. Use smallest amount of epinephrine in LA
(not more than 1/ 100, 000) Or preferably use
CORBASIL / octapresine since it's effect is only 1/10
of epinephrine in raising the blood sugar
8. If there is any doubt of insulin shock / Diabetic
coma → IV dextrose
if diabetic coma → no harm
if insulin shock → dramatic correction
9. Sugar should always be available if hypoglycemic
shock occur

Dr.Elhawary
Diabetic Coma and Insulin Shock
Hypoglycemia
Insulin Shock
Hyperglycemia
Diabetic coma
Item
Drowsiness and loss of consciousnessConsciousness
moist & paledry & flushedSkin appearance
------------------IntenseThirst
NormalAcetoneBreath odor
RareCommonVomiting

Dr.Elhawary
HYPERTHYROIDISM
THYROTOXICOSIS /TOXIC GOITER / GRAVE’S DISEASE

Dr.Elhawary
• Condition :
– Increase secretion of thyroid hormones (T3, T4) in the
circulation that can lead to thyroid crisis
• Signs and symptoms of thyrotoxicosis:
1. Increased apatite and loss of weight
2. Warm moist skin
3. Irritability and nervousness
4. Fine tremors and muscle weakness
5. Increased cardiac output, pulse rate and blood pressure
6. Tachycardia
7. Dyspnea on exertion
8. Exophtalmous

Dr.Elhawary
• Dental Management Considerations
(Prevention of thyroid crisis):
1. Medical Consultation
2. Postpone surgery until thyroid dysfunction is well
controlled (1-2 months after controlling the case)
4. Avoid the use of vasoconstrictor
i. Use plain anesthesia
ii. Use local anesthesia with vasoconstrictor other than
Adrenaline / Noradrenaline
5. Avoid Atropine as it may lead to thyroid crisis

Dr.Elhawary
Thyroid Crisis
• Early symptoms of thyroid crisis
1. Restlessness
2. Nausea
3. Abdominal cramps
• Late symptoms of thyroid crisis
1. High fever
2. Tachycardia
3. High pulse rate with severe hypotension
4. Tachypnea due to pulmonary oedema
5. Coma and heart failure

Dr.Elhawary
Thyroid Crisis cont.
• Management of thyroid crisis:
1. Urgent call for medical aid
2. Cold packs to decrease temperature
3. Oxygen
4. Cardiopulmonary resuscitation
5. 100-300 mg hydrocortisone IV
6. Anti-thyroid medications e.g. potassium iodide or
200 mg propranolol
7. IV fluid as a supportive measures

Dr.Elhawary
ADRENAL INSUFFICIENCY
ADDISON'S DISEASE

Dr.Elhawary
• Adrenal suppression can be caused by :
1. Addison’s disease ( 1ry )
2. 2ry deficiency
i. Pituitary or Hypothalamic disease
ii. Prolonged corticosteroid therapy
• Adrenal cortical suppression should be suspected if
patient Take
(RULE OF TWO)
1. 20 mg or more of cortisone daily
2. 2 weeks or more
3. within last 2 years

Dr.Elhawary
2. Adjust the corticosteroid dose
Emergency
Patients who are
under corticosteroid
therapy
Patient who has taken
corticosteroids in the
last 2 years
125 mg of Solu- Medrol (
hydrocortisone ) is given
IV at the time of surgery
Normal dose is doubled
for 2 days following ttt
1.Double or triple the
dose day before
surgery
2.Day of surgery
3.2 days
postoperatively
4.Reinstitute normal
dose after that
1. Reinstitute the
previous dose of
corticosteroid 2 days
before the day of
surgery
2. Continue the steroid
therapy for one week
postoperatively
Management

Dr.Elhawary
4. Antibiotic therapy if extensive surgical procedures are
anticipitated or if one is operating in an infected surgical
field
5. GA is preferable for major surgeries
6. Preparation of the patient for General Anesthesia:
1. IM 100 mg hydrocortisone Night before operation
2. Repeat the dose immediately before operation
3. Sometimes anesthetist give IV drip ( cortisone ) during operation
time
4. Post operatively (Tapering)
1. 50 mg hydrocortisone after recovery
2. 1.5 – 2 times the normal oral dose on the 2nd day
3. Normal dose on the 3rd day

Dr.Elhawary
Adrenal Crisis
• Clinical features of adrenal crisis:
1. Sever Hypotension
2. Dehydration
3. Circulatory collapse
4. Shock
5. Respiratory collapse
N.B. Could lead to death if not treated
• Treatment of ADRENAL CRISIS:-
1. Pt in shock position
2. Oxygen
3. Administration of glucocorticoids:
1. Prednisolone IV or IM (4 times > cortisone)
2. Dexamethasone (25 times > cortisone)
4. Vasopressor drugs such as Wyamine sulphate
5. Fluid and electrolytes replacement
6. Hospitalization

Dr.Elhawary
LIVER DISEASES
LIVER CIRRHOSIS
HEPATITIS

Dr.Elhawary
Functions of the liver
1. Exocrine function by production of bile salts
2. Carbohydrates and lipids metabolism (glycogen storage)
3. Detoxification properties
4. Production of bilirubin from the break down of
haemoglobin
5. Production of :
i. Albumin
ii. Clotting factors (prothrombin and fibrinogen)
iii. Plasma proteins
iv. Urea
v. Amino acids

Dr.Elhawary
Impaired liver functions leads to:
1. Abnormalities in metabolic processes
2. Abnormalities in coagulation
3. Abnormalities in drug metabolism

Dr.Elhawary
Laboratory investigations used to
evaluate hepatic functions :
1. Serum bilrubin when elevated → intrahepatic or obstructivr liver
disease
2. Serum alkaline phosphatase when elevated → obstructive liver
disease rather than cellular liver disease
3. Serum transaminase levels when elevated → Hepatocellular necrosis
(NONSPECIFIC)
4. Serum albumin decreased late during liver diseases
5. Bromsulphalim (BSP) retention (MOST SPECIFIC)
6. Prothrombin time elevated in hepatic disease
7. Antigen antibody markers to differentiate different types of viral
hepatitis

Dr.Elhawary
LIVER DISEASES
LIVER CIRRHOSIS

Dr.Elhawary
• Condition:
– Hepatic parenchymal damage with fibrosis and
damage of the normal lobular pattern of liver
• Etiology:
1. Idiopathic
2. Alcoholism
3. Hepatitis
4. Liver autoimmune disease
5. Hepatotoxins

Dr.Elhawary
• Clinically:
1. Jaundice
2. Bleeding tendency
3. Portal hypertension
4. Ascites
5. Hypoglycemia
6. Hepatosplenomegaly

Dr.Elhawary
LIVER DISEASES
HEPATITIS

Dr.Elhawary
• Condition:
– Inflammation of the liver cells
• Etiology and Types:
1. Primary hepatitis:
i. Viral hepatitis
ii. Toxic hepatitis
iii. Drug induced hepatitis
2. Secondary hepatitis:
i. Syphilis
ii. TB
iii. Infective mononucleosis

Dr.Elhawary
• Clinically :
1. Anorexia or nausea
2. Fever which gradually subside
3. Enlargement and tenderness of liver
4. Splenomegaly
5. Jaundice
6. Lymphadenopathy
• Complications of hepatitis:
1. Degenerative necrosis of liver cells
2. Biochemical abnormalities
3. Liver cirrhosis
4. Hepatocellular carcinoma

Dr.Elhawary
• Dental management cosideration:
2. Liver function tests
3. Coagulation screening profile
4. Regulation of the bleeding tendency :
i. Blood transfusion prior to surgery if needed
ii. Vitamin K injection (10 mg synkavit 1 hour before and
after surgery)
6. Prophylactic antibiotics
7. High infection control measures

Dr.Elhawary
• Dental management cosideration:
8. Avoid hepatotoxic drugs
9. Minimize the use of drugs metabolized in liver
10. LA is safe with small doses and least concentrations
11. Least amount of surgical intervention

Dr.Elhawary
Drug therapy in liver diseases
PreferableTo be avoidedItem
ParacetamolMorphine
Valium
Asprin
Analgesics
Clindamycin
Metronidazole
Penicillin
Sulphonamides
Antibiotics
Ester types :
Procaine
Amide types :
mepivicain
xylocaine
Anesthesia

Dr.Elhawary
RENAL DISEASES
RENAL FAILURE
KIDNEY TRANSPLANTATION

Dr.Elhawary
RENAL DISEASES
RENAL FAILURE

Dr.Elhawary
• Clinically :
1. Nausea and vomiting
2. Loss of weight
3. Pallor
4. Anemia
5. Hypertension
6. Acidosis
7. Congestive heart failure
8. Pulmonary edema
9. Renal osteodystrophy
10.Elevated serum creatinine (0.6→1.2mg / 100ml blood)
11.Elevated BUN (blood urea nitrogen) (8 →23 mg)
• Treatment :
1. Artificial blood filtration (dialysis)
2. Kidney transplantation

Dr.Elhawary
Renal haemodialysis
3. Avoid drugs that are excreted through the kidneys
4. Avoid nephrotoxic drugs
5. Postpone till the same day (not before 4 hours) or better
day after dialysis
6. Prophylactic antibiotics to guard against SBE (SHUNT)
7. Least traumatic surgery
8. Least amount of LA

Dr.Elhawary
Renal Transplant
3. Regulation of the corticosteroids
1. Minimal stress → no change
2. Moderate stress → double the dose
3. severe stress → 100 mg hydrocortisone IV
4. Avoid nephrotoxic drugs
5. Prophylactic antibiotics to minimize bacteremia specially because
the patient is under the action of cytotoxic drugs

Dr.Elhawary
Drug therapy in renal diseases
Paracetamol
ibubrufen
Aspirin
NSAIDs
Analgesics
Erythromycin
Clindamycin
Metronidazole
Cephalosporens
Tetracycline
Antibiotics
xylocaine
ProcaineAnesthesia

Dr.Elhawary
MISCELLANEOUS
PREGNANCY AND LACTATION
EPILEPSY
HIV
OSTEORADIONECROSIS

Dr.Elhawary
MISCELLANEOUS
EPILEPSY

Dr.Elhawary
2. Postpone surgery until seizures are well controlled
3. Anticonvulsant Premedication
5. Avoid hypoglycemia
6. Avoid lengthy
• In case of seizures
1. Stop the procedure
2. Put patient in supine position
3. Place bite block or tongue blade between teeth

Dr.Elhawary
MISCELLANEOUS
HIV

Dr.Elhawary
• Acquired immune deficiency syndrome (AIDS)
• Condition :
1. Generalized lymphadinopathy
2. Opportunistic infections
3. Malignancies
4. Progressive periodontal disease without local factor
5. Hairy leukoplakia
6. Xerostomia
1. Consultation
2. Strict infection control measures

Dr.Elhawary
MISCELLANEOUS
PREGNANCY AND LACTATION

Dr.Elhawary
• Best time for the dental procedure is the middle or the
2nd trimester due to :
1. Minimal nausea and vomiting
2. Stable fetus
3. Low incidence of obstetrical complications
• Emergency treatment can be done at any time
• Dental procedures involves potentially harmful
elements for pregnant female including:
1. Radiographs
2. Drug administration
3. Pain and stress
4. Supine hypotension in late pregnancy

Dr.Elhawary
1. Consult the patient’s obstetrician
2. Short appointments
3. Avoid painful stimuli
4. Avoid placing the patient in supine position
5. Avoid radiographs
It should be limited and used only after 1st trimester
(if necessary use lead apron)
6. LA is more suitable than GA
7. Avoid drugs with teratogenic potential

Dr.Elhawary
Drugs contraindicated and alternatives in pregnancy
Paracetamol
Aspirin
NSAIDs
Analgesics
Penicillin
Erythromycin
Cephalosporin
Tetracycline
Aminoglycosides
Streptomycin
Metronidazole
Antibiotics
Corticosteroids
Others

Dr.Elhawary
All Preferable medications
has to be approved by the
patients Gynecologist

Dr.Elhawary
• Medications to avoid during lactation :
1. Ampicillin
2. Tetracycline
3. Aspirin
4. Steroids
5. Valium
6. Barbiturates
• Permissible drugs during lactation :
1. Keflex
2. Erythromycin
3. xylocaine

Dr.Elhawary
THANK YOU
H. ELHAWARY

Management of medically compromised patients

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Management of medically compromised patients

Similar to Management of medically compromised patients (20)

More from Hesham El-Hawary

More from Hesham El-Hawary (17)

Recently uploaded

Recently uploaded (20)

Management of medically compromised patients