this presentation shows how to manage medically compromised patients

1. Management of Medically
Compromised Patients in oral
surgery
DR. NAMANYA ROGERS (BDS)MUK

2. Cardiac Diseases
 Rheumatic heart disease
 Congestive cardiac failure,
 Valvular septal defects,
 Myocardial infarction
 Unstable angina
 Congenital heart diseases

3. Management
 Consultation with the patient’s physician
 Patient with Rheumatic heart disease/has undergone valve replacements -
a suitable antibiotic prophylaxis must be given.
 Example: Amoxicillin , Cephalexin, Clindamycin, Azithromycin

4. Hypertension
 BP>140/90 mm of mercury.
 It causes excessive bleeding from the operation site
 increases anesthetic risk to the patient under GA
 Patient’s BP should be controlled before any surgical procedure
 LA without adrenaline or bupivacaine, which does not have any significant
effect on the cardiac status is to be used
 Consultation

5. Respiratory Diseases
 Obstructive pulmonary diseases: asthma, chronic bronchitis,
pneumothorax and emphysema
 Infiltrative pulmonary diseases.
 If the patient is treated under LA, the bronchodilator inhaler should be
kept ready for use in case of an emergency.
 E.g salbutamol inhalers or can be used prophylactically before the
procedure if an attack is predicted
 Consultation

6. Renal Diseases
 Renal failure, acute glomerulonephritis, nephritic syndrome
 Consultation of the patient’s physician
 LA is safe unless there is severe bleeding tendency
 Prophylactic antibiotics are to be prescribed due to immunosuppression.
 proved safe antibiotics in renal diseases: Amoxicillin, doxycycline and
minocycline are a few recommended antibiotics
 Tetracycline should be avoided in chronic renal failure.
 Aspirin and NSAIDs should be avoided as they affect renal function

7. Hepatic Diseases
 Liver Cirrhosis, Liver cancer, Hepatitis B and C
 Consultation of the patient’s physian
 Liver disorders are important to the dentist due to a potential bleeding
tendency
 LFT
 LA is safe given in normal doses, but prilocain or articain are preferred to
lidocain
 Dentist should treat the patient within the current regulations for cross
infection control to avoid Hepatitis B infection

8. Diabetes Mellitus
 Caused by an absolute or relative deficiency of insulin in the body.
 Classified into type 1 (insulin dependent) and type 2 (noninsulin
dependent)
 Type 1 is more commonly seen in young patients
 Type 2 in adults.
 A patient can be classified as a diabetic, when his fasting glucose levels are
constantly above 140 mg/dl.
 These patient is prone to infections and they have poor wound healing
tendency
 Sugar levels must be controlled before any surgical procedure
 Pre- and postoperative broad spectrum antibiotic coverage.

9. Thyroid Disorders
 Hypothyroidism, Euthyroidism , Hyperthyroidism
 Hypothyroidism & Hyperthyroidism patients pose greater risk for any
surgical procedure
 Consultation of the patient’s physian before any surgical procedure

10. Adrenal Diseases
 Cushing’s syndrome (overproduction Cortisol) and Addison’s disease
(underproduction).
 Cortisol is sometimes called the “stress hormone” because it helps your
body respond to stress.
 Consultation of the patient’s physician before any surgical procedure

11. Neurological Disorders
 Cerebellar infarcts, aneurysms, and arterio-venous malformations are very
high risk candidates and are absolute contraindications for surgical
procedures.
 Consultation before any surgical procedure
 If the patient is an epileptic, adequate control of seizure episodes must be
achieved prior to the surgical procedure
 The anticonvulsant must be continued till the morning of the surgery.

12. Disorders of hemopoietic system
 Grouped into anemia , leukocyte disorders and coagulation factor
abnormalities (hemophilia)
 Anemia include iron deficiency anemia, thalassemia, sickle cell anemia
 Leukocyte disorders include leukocytosis and agranulocytosis
 Postoperative infection and delayed wound healing is also very high,
especially in agranulocytosis, leukemia and anemia.
 Consultation
 Cover the patient with adequate broad spectrum antibiotics

13. Management of a Hemophiliac Patient
 Two types: hemophilia A (Factor VIII deficiency) and Hemophilia B (Factor
IX deficiency).
 The disorder is a sex linked recessive trait.
 These patients have a tendency to bruise easily and have prolonged
bleeding.
 Build up factor VIII level to 50 to 70 percent(Consultation)
 Avoid injecting into deep tissue spaces, i.e. avoid block techniques. Use
infiltration anesthesia
 A traumatic extraction, surgical procedure
 Avoid unnecessary trauma to the soft tissues, avoid suturing if not
required

14. Immunocompromised Patients
 Patients having deficiency in cell mediated, humoral immunity, neutrophils,
complements
 Patients on chemo-therapeutic agents and steroids
 Diabetic and nutritional deficient patients
 These patients are highly susceptible to infections and must be given
broad spectrum antibiotic coverage
 While handling HIV infected patients, special care must be exercised to
prevent the transmission of the disease.

15. Autoimmune Disorders
 Examples: lupus erythematosus, scleroderma, collagen disorders,
rheumatoid arthritis, Sjögren’s syndrome, polyarthritis nodosa
 These patients may have significant cardiac, renal and bone marrow
impairment, which may contra-indicate elective surgery
 In scleroderma, the patients have a restricted oral opening as well as
restricted expansion of the chest wall.
 Patients with collagen disorders may also have delayed postoperative
wound healing.
 Consultation

16. Patients undergoing Radiation therapy
 Oral complications of radiotherapy involving the oral cavity and salivary
glands:
 Mucositis, Loss of taste (hypoguesia), Xerostomia and infections, Radiation
caries and dental hypersensitivity, Osteoradionecrosis and osteomyelitis,
Trismus , Dental defects( hypoplasia and retarded eruption.)
 Before radiation:
-Patients with healthy teeth and good oral hygiene present with few or no
complications after radiotherapy.
-Scaling & polishing plus mouthwashes ,Fillings , RCT start
-Extraction of hopeless teeth 2 weeks before radiotherapy
-No bone should be left exposed in the mouth

17. Cont’d
 During radiotherapy
-Chlorhexidine mouthwash maintains oral hygiene
-Mucositis may be relieved by using warm normal saline mouthwashes mixed
with some lignocaine
-Avoid Smoking and alcohol
-a saliva substitute such as carboxymethylcellulose
-Trismus may be reduced by instituting jaw-opening exercises
-Antifungal drug nystatin suspension as a mouthwash used four times daily
may be required

18. Cont’d
 After radiotherapy:
-Oral hygiene and preventive dental care should be continued
-Manage Mucositis
-Extractions may precipitate osteomyelitis, try to avoid
-Topical fluoride application to control caries and dental hypersensitivity
-Patients should be advised to avoid sweets things
-Instead sugar substitutes such as saccharin or aspartane, may be used
-Avoid dentures. they should be fitted at about 4 to 6 weeks after
radiotherapy,

19. Pregnancy and lactation
 Every female patient in the child-bearing age must be asked for history of
pregnancy or missed menstrual cycles.
 It is safe to perform procedures under local anesthesia in the 2rd trimester
 In 1st trimester, there is a risk of stress related abortion as well as
teratogenicity
 While in the 3rd trimester there is a risk of stress induced early labor
 Teratogenic drugs like tetracyclines, salicylates, and chloramphenicol are
best avoided.
 Amoxycillin, cloxacillin, ampicillin and Paracetamol can be safely
prescribed

20. Conclusion
 A thorough medical history should be obtained
 Have knowledge about the medications taken by the patient
 Consultation of the patient’s physician.
 Adequate and necessary preoperative investigations must be performed
 Informed consent from the patient
 Refer

21. Medical emergencies
In any medical emergency, apply “SPORT”
 Stop treatment
 Position patient
 Oxygen*
 Reassure
 Take vitals

22. Syncope (fainting)
 Most common medical emergency in Dental chair
 Vasovagal syncope-most common syncope due to needle anxiety
 Trendelenburg position
 Left lateral decubitus if pregnant to relieve inferior vena cava
 Orthostatic hypotension
2rd most common cause of syncope
 Dizzy spell or head rush
 Blood pressure suddenly falls
When standing-

23. Epinephrine overdose
 Rapid , intravascular injections
 Blood pressure and heart rate rise, thumping heart

24. Angina
 Stable vs unstable angina (chest pain at rest)
 Ischemia without necrosis
 ONA
 NTG ?(0.4mg)-5min-Nitroglycerine tab-5min-Nitroglycerine,aspirin and
call for an ambulance

25. Myocardial infection(MI)
 Sudden occlusion of major coronary vessel, usually left anterior
descending artery (LAD)
 Ischemia with necrosis
 MONA

26. Hypoglycemia/Diabetes
 If conscious-glucose tab or orange juice
 If unconscious-IV dextrose or IM glucagon

27. Hyperventilation
 Do not give oxygen
 Sit upright
 Brown paper bag

28. Asthma
 Constriction and inflammation of bronchioles
 Wheezing –high pitch on exhale
 2 puffs from emergency inhaler (albuterol)
 Avoid NSAIDs and nacrotics

29. Airway Obstruction
 Clear the pharynx of any food , vomit, or foreign objects
 Check for breathing (rise and fall of chest , sound of mouth or nose)
 Chin tilt upwards to extend the neck
 Protrude tongue and mandible to open airway

30. Seizure/Convulsion
 Protect from injury
 Do not restrain
 IV or IM benzo
 Grand mal seizure = Dilantin/Phenytoin
 Status epilepticus = Valium / Diazepam

31. Stroke
 TIA = transient ischemic accident , mini-stroke
 CVA = Cerebrovascular accident , stroke
 Oxygen and call the ambulance
 Caused by hyponatremia
 Look for facial droop , arm drift ,speech slur

32. Anaphylactic Shock ( severe allergic
Reaction)
 AEIOU
 Albuterol
 Epinephrine (0.3 mg 1:1000)
 IM antihistamine
 Oxygen
 Call ambulance

33. Anticoagulation
Check blood tests below :
 - CBC – Anemia , leukopenia , thrombocytopenia
 - Bleeding time – platelet function
 - PT – anticoagulants, liver , Vitamin K
 - INR – Warfarin / Coumadin , INR=2-3
 - PTT – Heparin , renal dialysis , hemophilia
Herbal anticoagulants : Garlic , Ginger , Ginkgo , Ginseng