Medically compromised

1. PERIODONTAL TREATMENT
OF
MEDICALLY COMPROMISED
PATIENTS

2.  CARDIOVASCULAR DISEASE
 ENDOCRINE DISORDERS
 HEMORRHAGIC DISORDERS
 RENAL DISEASES
 LIVER DISEASES
 PULMONARY DISEASES
 MEDICATIONS AND CANCER THERAPIES
 INFECTIOUS DISEASES

3. s
 CARDIOVASCULAR DISEASE
 Hypertension
 Ischemic heart disease
 Previous cardiac bypass surgery
 Congestive cardiac failure
 Infective endocarditis
 Presence of cardiac pacemaker
 defibrillator

4. HYPERTENSION
 EVERY PT above 30yrs check bp
 Any discrepancy refer to physician
 Previously diagnosed case-check whether bp is controlled and type
of medication
 CALCIUM CHANNEL BLOCKER-gingival enlargement
 Hypertension divided into primary and secondary

5.  Consult physician explaining nature of periodontal
therapy
 Schedule appointments in afternoon
 Check bp before procedure
 If systolic greater than 180 mmHg and diastolic greater
than 110mmHg no treatment is provided
 Use LA with adrenaline concentration less than 1:100000
or less. Aspirate before injection to prevent depositing into
blood vessel.
 Keep procedures short
 Avoid intraligamentary injections
 Use conscious sedation in anxious patients
 Make sure bleeding stops completely before dismissing
patient
 Beware of postural hypotension while adjusting dental
chair

6. ISCHEMIC
HEARTDISEASE
 ANGINA AND MYOCARDIAL INFARCTION
 Consult pt’s physician and obtain fitness to undergo
periodontal therapy
 Instruct to bring medication-
nitroglycerin
 Procedures short
 Discontinue procedure if patient is
fatigued,uncomfortable

7. MI DENTAL
TREATMENTSHOULD
NOT BE DONE
FORATLEAST6
MONTHS
 If angina occur in dental chair
 Discontinue treatment
 Administer 0.3-0.6mg of nitroglycerin sublingually
 Reassure patient and loosen restrictive garments
 Administer oxygen to patient in reclined position
 If signs and symptoms subsided …within 3min..
Complete procedure as soon as possible
 If angina not resolved in 2-3 min administer another
dose of nitroglycerin, monitor pt’s vitals.Call patient’s
physician and be ready to accompany patient to
emergency department.
 3rd nitroglycerin tablet given in 3min after second. If
not relieved suggestive of MI .Shift to nearest
emergency medical facility immediately.
Because peak mortality occurs during this time

8. Bypasssurgery,femoral
arterybypass,
angioplasty,
endarterectomy
commonsurgical
procedure inthese
patients
 Consult pt’s physician before elective dental procedure.
 Prophylactic antibiotics not necessary for cardiac
bypass patients unless recommended by cardiologist.

9. CONGESTIVE
CARDIAC
FAILURE
 CONSULT pt physician
 At risk for sudden death
 Orthopnea- dental chair adjusted to comfortable level
other than supine position.
 Short appointment, oxygen supply , profound LA

10. CARDIAC
PACEMAKERS
 Older pacemaker –unipolar-disrupted by
electromagnetic field like ultrasonic and electrocautery
units.
 Newer ones-bipolar and not affected by dental
equipments
 Automatic cardioverter-defibrillator activate without
warning when certain arrythmias occur.Sudden
patient movements occur .Stabilise operating field
with bite blocks….

11. INFECTIVE
ENDOCARDITIS

12. CEREBROVASCULAR
ACCIDENT
 …..stroke……
 No periodontal therapy performed for 6
months …high risk for recurrence
 After 6 months… short appointments, minimal stress.
Profound LA …conc greater than 1:100000 are
contraindicated.
 Light conscious sedation can be used for anxious
patients.
 These patients- oral anticoagulants-perio surgery
bleeding…. Adjust dosage….after consulting physician
 Bp monitored…..

13. ENDOCRINE DISORDERS
 DIABETES
 THYROID
 ADRENAL INSUFFICIENCY

14. DIABETES
 If patient having undiagnosed diabetes
 Consult physician
 Analyse lab test.FBS,PPBS
 Rule out acute infection
 Non surgical debridement

15.  Managing diabetic patient in dental office
 Controlled diabetic and non surgical therapy –no
antibiotic…but before surgical procedures prophylactic
antibiotic recommended
 If long procedure.. Check blood glucose level to prevent
hypoglycaemia…. If level is high ..ask for Hb A1c
 If procedure last for hours.. Check levels during
procedure to ensure patient doesnot become
hypoglycaemic…

16.  Signs and symptoms of hypoglycaemia
 Tremors
 Confusion
 Agitation and anxiety
 Sweating
 Tachycardia
 Dizziness
 Feeling of impending doom
 Unconsciousness
 Seizures

17.  Managing hypoglycaemia
 15g of oral carbohydrate to patient
 4-60z of juice or soda
 3-4 tsp of table sugar
 Hard candy with 15 g of sugar
 If unable to take orally
 Give 25-30mL of 50% dextrose intravenous
 Give 1mg of glucagon IV
 Give 1mg of glucagon IM or subcutaneously….

18. Patientunder
insulin
 Insulin and not eating proper
meal….MAIN CAUSE FOR
HYPOGLYCAEMIA
 If patient restricted from eating before Rx (conscious
sedation) normal insulin doses need to be reduced….
 If procedures are long insulin before Rx may be
reduced
 If dietary restrictions after Rx adjust insulin dosage
 Consultation with pt physician….

19. Thyroidand
parathyroid
disorders
 Hyperthroidism… limit stress
 Hyperthyroidism causes tachycardia and other
arrythmias, increased cardiac output, myocardial
infarction
 Uncontrolled hyperthyroidism… need to be controlled
prior to perio therapy
 Epinephrine and other vasopressor amines should be
given with caution
 Hypothyroidism… careful administration of sedatives
and narcotics….
 Parathyroid disease… controlled… then only do
periodontal therapy….if hypercalcemia or
hypocalcaemia is present.. Can lead to cardiacs
arrhythmias…

20. Adrenal
insufficiency
Systemic corticosteroids used by
 Allergic, endocrine, respiratory, neurologic, renal, liver,
skin…. Disorders
 Complication with systemic corticosteroid usage
 Steroid induced diabetes, osteoporosis, altered wound
healing, suppression of HPA axis

21. HPAAXIS
 Healthy pts- stress activated HPA axis-endogenous
cortisol production byadrenal gland
 When systemic steroids are used (exogenous) suppress
HPA AXIS …impair pt ability to respond to stress (i.e
endogenous steroid prodn is affected)…..
 ACUTE ADRENAL CRISIS

22. MANAGEMENT
OFACUTE
ADRENALCRISIS
 Terminate perio Rx
 Give O2
 Monitor vital signs
 Place pt in supine position
 Administer 100mg hydrocortisone sodium succinate IV
over 30 seconds or IM

23.  Individuals at risk for adrenal crisis
 Lengthy major surgical procedure
 Significant blood loss
 Extremely low adrenal function
 Low adrenal fn identified by adrenocorticotropic
hormone (ACTH) stimulation test.
 In emergency situation increasing…. Steroid dose
before procedure can decrease chances of acute adrenal
crisis…
 Consult pt physician
 Stress reduction protocol
 Profound anaesthesia