essay 26 - teeth extractions in medically compromised patients teeth extractions in medically compromised patients(disorders of cardiovascular and respiratory systems). management

list some cardiovascular diseases

• ineffective endocarditis prophylaxis

• hypertension

• ischemic heart disease

• cardiac arrhythmias

What is ineffective Endocarditis prophylaxis, provide some symptoms

• it is a serious, potentially fatal microbial infection of the heart's endothelial lining or valves, often associated with congenital or acquired cardiac defects

• Symptoms = fever, heart murmur, Positive blood cultures, petechiae, splinter haemorrhages

what are some cardiac conditions for prophylaxis before tooth extraction (ineffective endocarditis prophylaxis)

• prosthetic heart valves

• previous infective endocarditis

• congenital heart disease

• heart transplant recipients with valvulopathy

what are some procedures requiring prophylaxis (ineffective endocarditis prophylaxis)

• manipulation of gingival tissue

• manipulation of periopical region of teeth

• manipulation of periopical region of teeth perforation of oral mucosa

what are some procedures not requiring prophylaxis (ineffective endocarditis prophylaxis)

• radiographs

• routine local anaesthesia through healthy tissue

• prostodontic/ orthodontic appliance placement

• appliance adjustments

• shedding of primary teeth and trauma related bleeding

antibiotic regimen (30-60 minutes Before procedures) - ineffective endocarditis prophylaxis

• amoxicillin - oral = adult 2g; Child 50 mg/kg

• ampicillin - IM/IV = adult 2g; child 50 mg/kg

• clindamycin - if allergic to penicilin = adult 600mg, child 20 mg/kg

• Azithromycin - if allergic to penicilin) = adult 500 mg, child 15 mg/kg

define hypertension and the classifications

• it is abnormal elevation in arterial blood pressure. the primary concern for dental treatment of hypertensive patients is that there is an extreme danger that there is an acute elevation in blood pressure as it can lead to stroke or myocardial infarction, this acute elevation can be caused by the release of catecholamines in response to stress or anxiety, or from vasoconstrictors (can be from the retraction code or from local anaesthetic)

causes of hypertension

• 90% of cases are primary Idiopathic hypertension

• chronic kidney disease

• thyroid or parathyroid disease

• glucocorticoid excess

• drug induced - chronic use of NSAIDs

what is the dental management of hypertension

• short, stress free morning appointments

• medical history e.g diagnosed with hypertension, how it's being treated, presence of symptoms

• monitor blood pressure pre and intraoperatively

• used modest amounts of epinephrine (max 0.036 mg)

• caution in patients on non selective beta blockers

• avoid orthostatic hypotension (change chair positions slowly)

• consider anxiolytic premedication if anxiety is high

• avoid extraction if BP is dangerously high (>179/109 mmHg) until stabilised

describe ischemic heart disease, give symptoms

• narrowing of coronary arteries due to atherosclerosis leading to myocardial ischemia

• Symptoms = chest pain chest pain(angina), breathlessness, fatigue and signs of congestive heart failure

what are the three determinants of dental management of ischemic heart disease

• severity of disease

• type and magnitude of dental procedure

• stability and reserve of patient

dental management for stable angina or past MI (>6 weeks ago)

• short, morning appointments

• stress reduction and pain control(operative and post operative)

• nitroglycerin readily available

• Limit vasoconstrictor use (epinephrine </= 0.036mg, 0.2mg levonordefrin)

• avoid anticholinergics e.g atropine

• antibiotic prophylaxis not required for stents or bypass history

if patient had MI (myocardial infarction) in past 30 days or has unstable angina, what precautions should be made

• defer elective procedures

• emergency care only with physician consultation

• consider: sedation, oxygen, prophylactic Nitro glycerine, ECG monitoring, blood pressure monitoring, pulse oximeter, cautious use of epinephrine in local anaesthetic

what are Cardiac arrhythmias, provides symptoms

• any variation in heartbeat, rhythm, rate or conduction pattern of the heart

• symptoms- palpitations, dizziness, syncope, shortness of breath, below 60 BPM, above 100 BPM, irregular rhythm, angina

dental management of cardiac arrhythmias

• stress and anxiety reduction - short morning appointments, comfortable chair position, post operative and intraoperative sedation

• limit vasoconstrictor (</= 0.036 mg epinephrine), risk of complications increases with dose

• avoid ultrasonic instruments and Electro surgery if pacemaker is present

• monitor INR If on anticoagulant (INR 2-3.5 is safe for extraction if patient takes anticoagulant)

• use local hemostatic measures

• avoid digoxin interactions and watch for toxicity, if on digoxin avoid epinephrine or levonodefrin

• consult physician for high risk cases, provide only a monthly treatment if necessary

precautions that should be taken if patient is on anticoagulants for example warfarin or sinthrome

• must have INR determined before any invasive procedure is performed

• if the procedure is extensive you must do the following:

• discontinue watering four days before surgery, there is a danger here as the patient may be in the temporary hypercoagulable state

• begin 30 mg of containers enoxoparine every 12 hours starting 3 days before surgery

• last dose of enoxaparin is at 9:00 PM the evening before surgery

• INR is checked on mroning of surgery and must be 1.0 or less

• an enoxoparin injections begin again on the evening after the surgery and warfarin too

• three days post OP the patients can stop enoxoparin

list some respiratory disorders

• chronic obstructive pulmonary disease

• asthma

what is chronic obstructive pulmonary disease - for respiratory disorder

• irreversible chronic air flow limitation due to chronic bronchitis or emphysema

dental management of chronic obstructive pulmonary disease

• Upright Chair Position

• avoid rubber dams and nitrous oxide sedation

• use pulse oximetry

• Administer supplemental oxygen if saturation <95%

• avoid barbiturates, narcotics, anticholinergics

• avoid macrolides and ciprofloxacin in patients on theophylline

• do not use outpatient general anaesthesia

describe asthma - Respiratory disorder - provide symptoms

• chronic inflammation and hyper responsiveness of airway

• Symptoms = dyspnea, wheezing, coughing (especially at night), chest tightness , tachypnea, chest tightness

dental management of asthma

• identify asthma severity and triggers, provide stress free environment

• ask patient to bring inhaler to the appointment

• avoid NSAID, aspirin, barbiturates and narcotics. Avoid macrolides in theophyline uses

• discontinued use of cimetidine 24hrs before intravenous sedation in patients taking theophyline

• use sulfite free anaesthetic if needed

• provide stress free environment

• sedation with nitrous oxide is OK in mild/ moderate asthma

what should be done during an asthma attack

• use short acting Beta 2 Agonist inhaler (e.g ventolin)

• Administer oxygen

• give epinephrine (0.3-0.5 ml of 1:1000) is severe

• repeat bronchodilator every 5 minutes if needed

• activate EMS