PERIODONTAL TREATMENT OF MEDICALLY COMPROMISED PATIENTS

CONTENTS

CARDIOVASCULAR DISEASES RESPIRATORY DISEASES ENDOCRINE DISEASES HEMORRHAGIC

DISORDERS

LIVER DISEASES RENAL DISEASES PREGNANCY AND INFECTIOUS

DISEASESMEDICATIONS AND CANCER

THERAPIES

INTRODUCTION

Many patient seeking dental care have significant medical conditions, that alter the course of their oral disease and therapy .

Older patient will have greater likelihood of underlying disease.

Therefore clinician responsibility includes recognition of patient medical problems and formulation of proper treatment plan.

CARDIOVASCULAR DISEASES

Most prevalent category ,Prevalence increases with age .

Periodontitis has been proposed as having an etiological or modulating role in

systemic diseases.

i. Proved by-locally produced mediators such as CRP,1L-1band ,1L-6) and TNF-a.

ii. Another indirect effect by heat shock protein which cross-react with the heart . Saini R et al.Ann Card Anaesth. 2010;13:159–161.

Cardiovascular disease includes –.

HYPERTENSION

Most common CVS disease

If hypertension undiagnosed Leads to CHF , CVA ,angina , MI or Kidney failure So dentist can play a vital role in detection of hypertension

1.Primary hypertension95% Without underlying pathology

2.Secondary hypertension 5%With underlying pathology as renal disease, endocrine changes and neurological disorders.

CLASSIFICATION

Chobanian av etal ,JAMA 2003

PROPHYLACTIC MEASURES

Unless accurate reading of BP, Periodontal treatment shouldn’t be performed .

BP varies through the day so time should also be written.

Family history and history of medication should be taken.

Dental considerations in cardiovascular patients: A practical perspective .2015

GENAERAL MEASURES

Medical consent is warranted if patient is hypertensive.

Dentist should also inform about type of periodontal treatment and degree of stress .

Afternoon session is better according to new evidences. RAAB FJ ETAL ,J AM DENTAL

ASSOCIATION 1998

No dental treatment for those patient who is hypertensive and not on medication.

Treatment should be limited to emergency for those patients with BP>180/110.

Continued…..

LA with epinephrine >1:1L shouldn’t be used and aspiration must be done .

Profound LA and conscious sedation is warranted for anxious patients.

Intraligamentary injection -contraindicated

Clinician should be aware of various side effects of medication

ISCHEMIC HEART DISEASE

when oxygen demands increases more than supply.

Results in temporary myocardial ischemia. Includes myocardial infarction and angina pectoris

• Irregular on multiple occasion without predisposing factors

• Treatment only, if emergencyUNSTABLE ANGINA

• Occurs infrequently and associated with exertion and stress.

• Can undergo elective dental procedures

STABLE ANGINA

PROPHYLACTIC MEASURES DURING DENTAL TREATMENT

Profound LA and conscious sedation -Anxious Pt

Morning and Short appointments Supplement oxygen-4-6 lit/min

Ask Patient to carry medication

Nitroglycerin- dental emergency kit

Avoid LA with epinephrineIf ANGINA pt feels uncomfortable, discontinue treatment

PATIENT WITH ANGINA ON DENTAL CHAIR SHOULD RECEIVE

MYOCARDIAL INFARCTION

Another category of IHD ,Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle

After 6 months of MI ,dental treatment similar to angina patient.

Jowett NI et al Cabot,Br Dental J. 2000.

Elective dental therapy-on the basis of degree of heart damage and stability of patient condition

Prophylactic antibiotic-given when recommended by cardiologist.

TREATMENT Stop dental treatment Call for help Rest, sit up and reassure patient Oxygen Analgesia (opiate, sublingual nitrate) and Aspirin

ThrombolysisBeta-Blockers and ACE inhibitors Prepare for basic life support Transfer patient to hospital

CONGESTIVE HEART FAILURE

It is the inability of heart to pump sufficient amount of oxygenated blood to meet the metabolic body needs .

Usually begins with left ventricular failure, caused by disproportion between hemodynamic load and capacity to handle that load

SYMPTOMS OF HEART FAILURE

1.Compensated (Asymptomatic) 2.Uncompensated (Symptomatic)

FUNCTIONAL CLASSIFICATION OF HEART FAILURE

Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity Class II: Slight limitation of physical activity. Fatigue, palpitations and dyspnea with ordinary physical activity but comfortable at rest.

Class III: Marked limitation of

activity. Less than ordinary physical activity results in symptoms but comfortable at rest. Class IV: Symptoms present at rest and any physical activity exacerbates the symptoms

Undiagnosed HF Pt with symptoms- Avoid elective care and refer to physician

For patients with diagnosed HF: Class I(asymptomatic): Routine care

Class II (mild symptoms with exertion): elective care and recommend consultation with physician

Class III or IV (symptoms with minimal activity or at rest): avoid elective care; if treatment necessary, manage in consultation with physician; consider referral to a special patient care setting; avoid use of vasoconstrictors

The dental chair- partially reclining or erect position and patient should be raised slowly in upright position. Emergency dental care should be conservative, principally with analgesics and antibiotics. Short and non stressful appointments Patients are best treated in late morning because of epinephrine levels peak in early morning.

PROPHYLACTIC MEASURES DURING DENTAL TREATMENT

AVOID:

Bupivacaine -cardiotoxic. LA with epinephrine in patients taking beta blockers. Gingival retraction cords containing epinephrineNSAIDS other than aspirin should be avoided in patients taking ACE inhibitors (renal damage). Erythromycin and tetracycline to be avoided as they may induce digitalis toxicity

CARDIAC ARRYTHEMIA

Group of conditions with abnormal electrical activity in the heart. The heart beat may be too fast or too slow, and may be regular or irregular

DENTAL CONSIDERATIONS Same like other CVS diseases At end of appointment chair should be raised slowly to minimize orthostatic hypotension.

The equipments like pulp testers ,ultrasonic scalers, electrosurgical units should not be in close proximity.

Prophylactic antibiotics before and after treatment in recently placed pacemaker patients.

Dental treatment should not be carried out in patients with irregular pulse.

Previously c/a Bacterial endocarditisDisease in which microorganism colonize the damaged endocardium/heart valves.Low incidence ,but poor prognosis even with modern therapy.Causative Agents- Alpha Haemolytic streptococci and staphylococci AHA 2007- Antibiotic prophylaxis prevents infective endocarditis in small number of patients.AHA 2008 antibiotic prophylaxis should only be recommended for high risk groups.

INFECTIVE ENDOCARDITIS

PREVENTIVE MEASURESDefine the susceptible patient Provide oral hygiene instruction-oral rinses and gentle tooth brush .Antibiotic prophylaxis should be recommended during periodontal treatment with all high risk groups.If patient on penicillin as prophylaxis – alt to be givenPt with aggressive Periodontitis–tetracycline

ENDOCRINAL DISORDERS

Diabetes mellitus

Adrenal insufficiency

DM is a group of disorder characterize by hyperglycemia

resulting from defects in insulin secretion, insulin action

or both.

Periodontitis is 6th complication of DM

DIABETES MELLITUS

KNOWN DIABETIC PATIENTS

Inquire about the medication, the type, severity and control of diabetes, the physician treating the patient and the date of last visit

Patient’s recent glycated hemoglobin values. HbA1c < 8% - relatively good glycemic control; > 10% indicate poor control

When the level of control of diabetes is not known, consult patients physician and the treatment should be just limited to palliation

Short morning appointments should be preferred, reduces the risk of hypoglycemic episodes during the dental procedures

Source of glucose such as an orange juice must be available in the dental office to avoid hypoglycemic attacks

Prophylactic antibiotics for patients taking high doses of insulin to prevent post-operative infection are recommended

It's best to do surgery when blood sugar levels are within normal range

Most common diabetic emergency which a dentist encounters is hypoglycemia, it can lead to life-threatening consequences ,occurs when blood glucose level drops below 60 mg/dL .

Confusion, sweating, tremors, agitation, anxiety, dizziness, tingling or numbness, and tachycardia. Severe hypoglycemia may result in seizures or loss of consciousness

As soon as such signs or symptoms are present the dentist should check the blood glucose with a glucometer,, the “Golden Rule” is that manage the patients as if they are hypoglycemic until proven otherwise

Management of Insulin Shock

Most common cause of adrenal insufficiency is chronic therapeutic corticosteroid administration.

1. Consult the physician and modify the doses2. Use an anxiety-reduction protocol.3. Monitor pulse and blood pressure before, during, and after surgery.

Management of Patient with Adrenal Suppression

ADRENAL INSUFFICIENCY

• Abdominal pain• Confusion• Feeling of extreme fatigue• Hypotension• Myalgia• Nausea• Partial or total loss of consciousness• Weakness

Manifestations of Acute Adrenal Insufficiency

1. Terminate all dental treatment.2. Place the patient in the supine position, with legs raised above level of head.3.Administer corticosteroid (100 mg hydrocortisone IM or IV ),fluid and electrolytes.4. Administer oxygen.5.Monitor the vital signs.6. Start an intravenous line and a drip of crystalloid solution.7. Start basic life support (BLS), if necessary.8. Transport the patient to an emergency care facility

EMERGENCY FOR PATIENTS HAVE ACUTE ADRENAL INSUFFICIENCY

PULMONARY PROBLEMS •ASTHMA •CHRONIC OBSTRUCTIVE PULMONARY DISEASE

• Characterized by reversible airway obstruction and associated with a

reduction in expiratory airflow

• Emotional stress-precipitating factor• MANAGEMENT • Avoid the use of nonsteroidal anti-inflammatory drugs

(NSAIDs) in susceptible patients. • Morphine is contraindicated • Bronchodilator inhaler should be available.• If the patient has been chronically taking

corticosteroids, provide prophylaxis for adrenal insufficiency

Asthma

Management of the Patient with Asthma

Irreversible airway obstruction; occurs with either chronic

bronchitis or emphysema

Chronic bronchitis is a result of chronic inflammation of

the airways and excessive sputum production

Emphysema is characterized by alveolar destruction with

airspace enlargement and airway collapse

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

About 10% of the population has some form of pulmonary

disease

With severe COPD, develop pulmonary hypertension,

increasing the risk for cardiac arrhythmias

Stress should be minimized and adrenal supplementation

instituted if the patients are taking certain doses of steroids.

DENTAL IMPLICATIONS OF THE RESPIRATORY DRUGS

Nonthrombocytopenic purpuras Thrombocytopenic purpurasDisorders of coagulation

ETIOLOGY

HEMORRHAGIC DISORDERS

1. primary 2. secondary : Chemicals-mitomycin C Physical agent - Radiation Systemic disease -leukemia

1. vascular wall alteration : infection, chemical, allergy 2. Disorder of platelet function : Genetic defects (bernard-soulier disease Aspirin, NSAIDs

broad-spectrum antibiotic Ampicillin, Penicillin, Gentamycin, Vancomycin)

Autoimmune disease

THROMBOCYTOPENIA PURPURA

NONTHROMBOCYTOPENIA

1. Inherited : Hemophilia A Christmas disease von Willebrand's Disease 2. Acquired : Liver disease Vitamin K deficiency Anticoagulation drugs (heparin, coumarin) Anemia

DISORDERS OF COAGULATION

Take historyPhysical examinationScreening clinical laboratory tests Observation of excessive bleeding following a surgical procedure

Evaluation of bleeding disorders

HISTORYBleeding problems in relativesBleeding problems following operations and tooth extractions,traumaUse of drugs for prevention of coagulation or painSpontaneous bleeding from nose mouth etc..

Jaundice Petechiae ：< 0.2 cmPurpura ： 0.2 cm-1 cmEccymoses ：> 1 cmOral ulcerHyperplasia of gingivaHemarthrosis

PHYSICAL EXAMINATION

Screening laboratory tests 1. Platelet count 2. BT (Bleeding Time) 3. PT (Prothrombin Time) 4. aPTT (active Partial Thrombopastin Time) 5. TT (Thrombin Time)

1. Patient with no history of bleeding disorders, normal examinations, no

medications associated with bleeding disorders and normal bleeding

parameters

2. Patients with nonspecific history of excessive bleeding with normal

bleeding parameters (PT, PTT, BT, platelet count are within normal time

Patient at moderate risk

3. Patients in chronic oral anticoagulant therapy (coumarin derivatives)

4. Patients on chronic aspirin therapy

Patient at low risk

1. patients with known bleeding disorders Thrombocytopenia Clotting factor defects2. Patient without known bleeding disorders found to have abnormal , platelet count, BT, PT, PTT

Patient at high risk

HEPARIN Complex inhibited ( IXa, Xa, XIa, XIIa )Used in deep vein thrombosis , renal dialysisRapid onset, Duration 4-6hrs ( given IV )Monitoring by aPTT: 50-65 secDiscontinue 6 hrs before surgery then reinstituting therapy 6-12hrs post –op and Protamine sulfate can reverse the effect

ANTICOAGULANT MEDICATION

COUMARIN (VIT K ANATAGONIST) Inhibit Vit K action (Factor II,VII,IX,X)Duration haft-life 40hrsMonitored by PT : INR 1.5-2.5 Alteration of coumar dosage ( 2-3 days )

Inhibit cycloxygenase, TxA2 formation Impairs platelet functionTests-BT, aPTTIf tests are abnormal,physcian should be consulted before dental surgery Stop aspirin for 5 days, substitute alternative drug in consultation with MD

Aspirin (antiplatelet)

Disease in number of circulation plateletsIdiopathic thrombocytopenia, secondary thrombocytopeniaTX : is none indicated unless platelets<20000/mm3, or excessive bleedingTX : Steroid, platelet transfusion

Thrombocytopenia

Gene mutation on Von Willebrand’s factor; most common Inherited disease in America ( 1% )Type I : 70%-80%, partial loss on quantityType II : poor on quality Type III : severe loss on quantity, inactive to DDAVP

VON WILLEBRANDIS DISEASE

Sex-linked recessive traitProlong aPTT, normal BT,PTSeverity of disorder : severe<1%, moderate 1-5%, mild 6-30%TX : Replacement factors, antifibrinilytic agents, steroids

HEMOPHILIA

Preventive dentistry 1. tooth brushing, flossing, rubber cup prophylaxis &topical

fluoride, supragingival scaling without prior replacement therapy

Pain control 1. block anesthesia: factor level>50% 2. Avoid aspirin, NSAIDsPeriodontal therapy 1. no contraindication of probing and supragingival scaling 2. deep scaling, curettage, surgery need replacement therapy

HEMOPHILIA-DENTAL MANAGEMENT

Replacement therapy : 1. platelet concentrate : thrombocytopenia ( 1 unit= 30,000/ uL enough for 1 day ) 2. Fresh frozen plasma : liver disease, Hemophilia B, vWD type III 3. Factor VIII,IX concentrate : Hemophilia A ( 1 unit /kg can add 2%, so 50 unit /kg add 100% ) 4. Factor IX concentrate : Hemophilia B 5. DDAVP : Hemophilia A, vWD type I,II

Antifibrinolytic therapy: 1. E-aminocaproic acid (EACA) 2. Tranexamic acid (AMCA, Transamin) LOCAL HEMOSTATIC METHODS

DENTAL MANAGEMENT OF BLEEDING DISORDERS

CONCLUSIONIn managing medically compromised patients, the clinician should always obtain a physcian consult before any periodontal treatment.

Changes in recommendations for medically compromised patients are continually occurring.

Dentists should follow the recommendations from the patient’ physician and utilize the appropriate protocol.

Dentists have the responsibility to understand the role of

periodontal inflammation in accentuating certain systemic

diseases (e.g., arteriosclerosis, diabetes, and preterm low

birth-weight infants.

Thus all clinicians need to be cognizant of the systemic

implications of periodontal diseases and their treatment, and

should stay up to date to give the best possible treatment.

REFERENCES

1CARRANZA 11TH EDITION2.DENTAL MANAGEMENT CONSIDERATION FOR DIABETIC PATIENT.RAJESH ET AL JADA VOL 132,20033. TR E A T M E N T O F H E M O P H I L I A MAY 2006 • NOV 404.DENTAL CONSIDERATIONS IN CARDIOVASCULAR PATIENTS: A PRACTICAL PERSPECTIVE SWANTIKA CHAUDHRY A,*, RITIKA JAISWAL A, SURENDER SACHDEVA ,JANUARY 2016