Lyceum-Northwestern University College of DentistryS.Y. 2015-2016

Pretreatment Evaluation and Management of Medically Compromised Patients In Dental Surgery

Submitted by:Mary G. CruzMay Ann PeraltaSheila May AlipioRowena QuimsonWang TingSubmitted to:Dr. Dominic JojiParado

PRETREATMENT EVALUATIONMedical history Medical History is most useful information a clinician can have when deciding whether a patient can safely undergo planned dental therapy Standard format for recording results of history and physical examinations:1) Biographic Data: include the patient's fullname,homeaddress,age,gender,andoccupation,as well as the name of the patient's primary care physician2) Chief complaint3) History of chief complaint : the patient should be asked to describe the history of the present complaint or illness4) Social and family medical history Baseline health history databasea. Past hospitalizations, operations, traumatic injuries and serious illnessesb. Recent minor illness or symptomsc. Medications currently or recently inuse and allergies (particularly drug allergies)d. Description of health-related habits or addictions such as the use of ethanol,tobacco,and illicit drugs,and the amount and type of daily exercisee. Data and result of last medical checkup or physician visit

This is helpful to inquire specifically about common medical problems that are likely to alter the dental management of the patient can be useful and should focus on relevant inherited disease such as hemophilia5) Review of systems: the medical review of systems is a sequential,comprehensive method of eliciting patient symptoms on an organ-by-organ basis. such as the cardiovascular and respiratory require evaluation before oral surgery or sedation. Head:headache,dizziness.. Ears:decreasedhearing,tinnitus... Eyes:blurring,double vision... Nose and sinuses: pain,change in sense of smell TMJ area:pain,noise,limited jaw motion locking Oral dental pain or sensitivity,lip or mucosal sores,bad breath Neck: difficltyswallowing,change in voice,pain,stiffness Constitutional:fever,chills,sweats,fatigue..6) Physical Examination : this one is focuses on the oral cavity and, to a lesser,on the entire maxillofacial region.7) Laboratory and imaging resultsManagement of Patient with Cardiovascular Problems

Ischemic Heart DiseaseThe basic disease process is a progressive narrowing or spasm or both of one or more of the coronary arteries.Angina Pectoris (substernal region) in the patients is a symptom of ischemic heart disease, characterized by a severe, viselike pain in the chest that sometimes radiates to the arms, neck, back and mandible. It is produced when myocardial blood supply cannot be sufficiently increased to meet the increased oxygen requirements that result from coronary artery disease.Management of Patient with Ischemic Heart Disease: 1. Consult patients physician.2. Use anxiety reduction protocol.3. Have nitroglycerin tablet or spray readily available.4. Ensure profound local anesthesia before starting a surgery.5. Consider use of Nitrous Oxide Sedation.6. Monitor vital signs closely.7. Consider possible limitation in the amount of epinephrine used.(0.04mg maximum).8. Maintain verbal contact of patient throughout the procedure to monitor status. Myocardial Infarction or MIIt occurs when ischemia causes myocardial cellular dysfunction and death. When an area of coronary artery narrowing has a clot form that blocks all or most blood flow MI may occur. The infracted area becomes nonfunctional and necrotic and is surrounded by an area of usually reversibly ischemic myocardium that is prone to serve as a nidus for dysrhytmias. During early hours or weeks after an MI and thrombolytic treatment was unsuccessful limit myocardial work requirements. Pacemaker insertion may be necessary if the patients survives the early weeks after MI since the will be replaced by a scar tissue that is unable to contract or properly conduct electrical signals. Elective major surgical procedures should be deferred until at least 6 months after an infarction. If the patient had undergone an advent thrombolytic-based treatment and had improved MI care an automatic 6-month wait to do dental work is unnecessary if the procedure is unlikely to provoke significant anxiety and the patient had uneventful recovery from MI.Management of Patient with History of Myocardial Infarction: 1. Consult patients physician.2. Check with the physician if invasive dental care is needed before 6 months since the MI.3. Check if the patient is using anticoagulants(including aspirin)4. Use anxiety reduction protocol.5. Have nitroglycerin readily available.6. Administer supplemental oxygen (optional)7. Ensure profound local anesthesia before starting a surgery.8. Consider use of Nitrous Oxide Sedation.9. Monitor vital signs closely.10. Consider possible limitation in the amount of epinephrine used (0.04mg maximum).11. Consider referral to oral-maxillofacial surgeon. In general, with respect to major oral surgical care, patients who have had coronary artery bypass grafting (CABG) are treated in a manner similar to patients who have MI since patients who have had CABG usually have a history of angina. Before major elective surgery is performed, 3months are allowed to lapse. If major surgery is necessary earlier than 3 months after CABG, the patients physician should be consulted. Cerebrovascular accident/ CVA (stroke) Patients who have had a CVA are always susceptible to further neurovascular accidents. These patients are often prescribed with anticoagulants and, if hypertensive, are taking blood-lowering agents. If the patients requires surgery, clearance by the patients physician is desirable. The patients baseline neurologic status should be assessed and documented properly. If pharmacologic sedation is necessary, low concentrations from nitrous oxide . Dysrhythmias People who are prone to or have cardiac dysrhythmias usually have a history of ischemic heart disease requiring dental management modifications. These patients may have been prescribed by anticoagulants or have a permanent cardiac pacemaker. Pacemakers pose no contraindications to surgery, and no evidence exists that shows the need for antibiotic prophylaxis. Congestive heart failure( Hypertrophic cardiomyopathy)/ CHF Patients with CHF who are under a physicians care are usually following a low-sodium to reduce fluid retention and are receiving diuretics to reduce intravascular volume. Patients with prevent chronic atrial fibrillation due to Hypertrophic cardiomyopathy are usually prescribed with anticoagulants. Patients with orthopnea should not be placed in supine position . Patients with CHF that is well compensated through dietary and drug therapy can safely undergo ambulatory oral surgery. Symptoms : Orthopnea, paroxysmal nocturnal dyspnea and ankle edema.Management of Patient with Congestive heart failure:1. Defer treatment until heart function has been medically improvedand the patients physician believes treatment is possible.2. Use an anxiety reduction control.3. Consider possible administration of supplemental oxygen.4. Avoid using the supine position.5. Consider referral to a oral-maxillofacial surgeon.Management of a Patient with Asthma 1. Defer dental treatment until the asthma is well controlled and the patient has no signs of a respiratory tract infection. 2. Listen to the chest with the stethoscope to detect any wheezing before major oral surgical procedures or sedation. 3. Use an anxiety - reduction protocol, including nitrous oxide, but avoid the use of respiratory depressants. 4. Consult the patient's physician about possible preoperative use of Cromolyn Sodium. 5. If a patient is or has been chronically taking corticosteroids, provide prophylaxis for adrenal insufficiency. 6. Keep a bronchodilator-containing inhaler easily accessible. 7. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in susceptible patient.

MANAGEMENT OF PATIENT WITH NEUROLOGIC DISORDERS

SEIZURE A sudden excessive discharge of electrical activity in the brain that usually causes a change in behavior. A symptom of an underlying disorder that affects the brain.

Etiological factors associated with seizures: Familial Unknown etiology Metabolic disturbances Trauma Space-occupying lesions Cerebrovascular accidents(CVA) or stroke Drug addiction Cerebral infection Other causes (stress, lack of sleep, flickering lights, alcohol, touch)

Seizure is classified as: Partial Simple Complex Generalized

Management of Patient with a Seizure Disorder 1. Defer surgery until the seizures are well controlled.2. Consider having serum levels of anti-seizure medications measured if patient compliance is questionable.3. Use an anxiety-reduction protocol.4. Take measures to avoid hypoglycemia and fatigue in the patient.5. If a patient has a seizure during a dental appointment, the only thing to do is to allow them to go through their seizure while during the event.

SEIZURE MEDICATIONS Always check for a history of alcohol use during history-taking. All antiseizure drugs can increase the effectiveness of centrally acting pain medications and muscle relaxants. Avoid centrally acting pain medications, sedatives, narcotics and sedating antihistamines with antiseizure medications. Use regular-strength acetaminophen (Tylenol) only. Phenytoin (Dilantin), Carbamazepine (Tegretol), Primidone (Mysolin) and Phenobarbital (Luminal) are the most potent hepatic enzyme inducers at therapeutic doses. Use doxycycline, clarithromycin, steroids and metronidazole with extreme caution if you plan on using any one of them. Always provide long-term xerostomia management when needed. Dilantin and primidone cause folic acid deficiency and macrocytic anemia. Phenytoin (Dilantin) causes gingivalhyperplasia. It is best to schedule hygiene recall every 3-4 months to control the hyperplasia. Primidone and Topiramate cause osteoporosis. Always check the bone density on the dentl radiographs. Topiramate causes taste changes and parasthesias in the head and limbs. Always confirm the presence of these sx prior to injecting the local anesthetic. Valproic acid enhances the effects of pain medications and anesthetics to use decreased doses or decreased amounts of the drugs Check the CBC, calculate the ANC, and determine the PT/INR, if the patient is on valproic acid for reasons previously discussed. The patient may need antibiotics to prevent and/or treat an infection. Check the CBC for pancytopenia if the patient ison thosuximide. The patient may need antibiotics to prevent and/or treat an infection. Phenobarbital and primidone depress the CNS and the patient could be sleepy in the chair. Limit the use of local anesthetics with epinephrine to 2 carpules inpatients with well-controlled seizure activity, or in patients with a history of very infrequent seizures. Epinephrine should be avoided in patients with frequently recurring seizures.

MANAGEMENT OF PATIENT WHO IS PREGNANT Pregnancy has been considered an impediment to dental treatment However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning

Pregnancy and Trimesters The 40 weeks of pregnancy are divided into 3 trimesters: First trimester (1-14 weeks) Second trimester (14-28 weeks) Third trimester (28-40 weeks)

Stages of Pregnancy 1. First Trimester (1-14 weeks) Fetal organ formation and differentiation. Greater risk of susceptibility to stress and teratogens Stages of Pregnancy 2. 2nd Trimester (14-28 weeks) Fetal growth and maturation Safest period for providing dental care during pregnancy Organogenesis is completed Stages of Pregnancy 3. 3rd Trimester (28-40 weeks) Fetal growth continues. Although there is no risk to the fetus during this trimester, the pregnant mother may experience an increasing level of discomfort It is safe to perform routine dental treatment in the early part of the third trimester, but from the middle of the third trimester routine dental treatment should be avoided Assessment During the Initial Dental Visit Determine the stage of pregnancy Determine if the px is experiencing any pregnancy-associated symptoms that need to be accommodated. Assess if she is presenting with acute dental problems or if the px is in for routine dental care. All emergency and routine care can continue during pregnancy. You must make provisions for and confirm her comfort in the dental chair throughout the duration of the dental appointment.

Pregnancy-Associated Signs and Symptoms Amenorrhea Nausea and vomiting Urinary frequency Fatigue

Pregnancy Tests Tests confirming pregnancy: Urine pregnancy test Serum pregnancy test

Physiologic Changes in Pregnancy Dietary Changes The daily caloric protein and folic acid requirements increase. The patient gains about 25-35lb throughout the pregnancy. Cardiovascular Changes Pulse PR increases by 10-15 beats/min Cardiac Output CO increases by 40% in the 1st trimester Supine hypotension usually occurs in the 3rd trimester due to compression of the inferior vena cava by the gravid uterus

Gastrointestinal Changes The gastric emptying is delayed and this accounts for the increased risk of aspiration.

Oral Cavity Changes Pregnancy Gingivitis There is an increased incidence of inflammation, erythema, edema and hypertrophy of the gums with pregnancy gingivitis. Pregnancy-associated hormonal changes cause increased growth of gum capillaries resulting in hypertrophy of the gums. The shift in hormonal changes also causes a shift in the bacterial flora and increased bacterial growth at the gum-line. The gums swell, bleed easily and become sensitive. Pregnancy Tumor Also called pyogenic granuloma, is a pedunculated outgrowth from the palatal surface of the gingiva and is usually found between the teeth or is associated with areas of local trauma or irritation. It is painless and appears as a soft, gray tissue mass with a red border. Surgical excision after birth is the treatment of choice, but it can recur.

The primary concern when providing care for a pregnant patient is the prevention of genetic damage to the fetus. Two areas of oral surgical management with potential for creating fetal damage are: Dental imaging Drug administration

Questions that a dentist may ask Can I take x-rays? Can I inject local anesthesia with epinephrine? What medications can I prescribe? Are topical agents safe? When should I perform necessary procedures? Can I use mercury restorations?

Use of Radiation on Pregnant Patient Dose given and time of gestation are important Radiation exposure 5RADS. Even multiple x-ray exposures seldom result in this level. During routine maternal dental x-rays, the fetal exposure is