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MEDICALLY COMPROMISED PATIENTS ; ORAL HEALTH CONSIDERATIONS
A brief
1-asymptomatic BP= below 159/99, no target organ disease --->no dental modifications needed, can safely be treated in a dental outpatient setting.
2-asymptomatic BP= 160-179/100-109, no history of target organ disease
--->assessment on individual basis with regard to type of dental procedure.
3-BP > 180/110, no history of target organ disease ---> no elective dental care.
4-target organ disease or poorly controlled DM---> elective dental care only when BP is controlled preferably.
1-if bleeding time >15-20 minutes --->1 desamino-8-D-arginine vasopressin (DDAVP) is administered parenterally 0.3ug per kg of body weight within 1 hour of surgery.
2-3 different protocols (elevated INR):
a) warfarin is not discontinued
b) warfarin therapy is discontinued; 2-3 days before and 2-3 days after surgery
c) warfarin therapy is discontinued and replaced with heparin
- Valvular heart disease (mitral/aortic/prosthetic)
1- (AHA)
2- the risk of thromboembolism increases for prosthetic heart valve patients is anticoagulation therapy is discontinued. It is prudent to continue anticoagulation therapy in patients who require intensive high INR levels.
1- no special modifications unless the underlying causes for the heart failure require modifications.
2 - lying down flat (supine) in a dental chair may cause severe dyspnea in such patients.
- Gastroesophageal reflux disease (GERD)
1-patients may complain of dysgeusia, dental sensitivity, erosion or pulpitis.
2-may need to treat in a semisupine position and premedicated with H2 receptor antagonists or antacids.
3-cimetidine inhibits the absorption of the systemic antifungal drug ketoconazole --->blood concentration (remember!)
1-may have xerostomia due to medications used--->tx: artificial saliva, alcohol-free mouthwash, increase fluid intake
2-may have class V caries or root caries--->because of xerostomia
3- may have oral manifestations such as GERD--->if reflux into oral cavity
1-avoid lengthy dental procedures--->minimize stress!
2-avoid administering drugs that exacerbate ulceration and cause GI distress (aspirin, NSAIDS)
3-acetaminophen products are preferable and are recommended.
4-may need sedation--->if stressful
5-antibiotics should be taken 2 hours before/2 hours after ingestion of antacids--->because antacids decrease absorption of antibiotics!
6-avoid exogenous steroid administration---> increase acid production!
7- prescribe penicillin V instead of penicillin G --->destruction of penicillin G by gastric acid!
1-the risks associated with anemia contraindicate surgical treatment until the disease is under control.
2-may have apthous stomatitis--->nutritional deficiencies of iron, folic acid and vit. B12 or blood loss!
3- anti inflammatory medications such as 5-aminosalicylates can cause apthous ulcers.
4-pyoderma gangrenosum may occur.
1-may reveal mucosal ulceration.
2-before surgical procedures are formed;
-complete blood count
-hematocrit
-hemoglobin test
-platelet count
-coagulation studies
-liver function test
-blood glucose test
1-may have--->jaundice, petechiea & ecchymoses, gingival crevicular hemorrhage, thrombocytopenia, pallor, angular chelitis, glossitis, sweet ketone breath.
2-should warrant a referral to the patient's primary care physician for evaluation.
3-elective dental treatment should not be carried out in a patient who has ingested a large amount of alcohol.
1-may have--->angular chelitis, glossitis, mucosal pallor, yellow pigmentation on oral mucosa, salivary gland dysfunction.
2-lab evaluation before any surgical /periodontal procedures should be obtained--->patients may have significant hemostatic defects.
3-avoid the use of sedatives and tranqulizers in patients with a history of taking encephalopathy narcotics.
1-may have--->purplish red discolouration of the oral mucosa, reddish gingiva, petechiae and ecchymoses, varicosities in the ventral tongue.
2-possibility of bleeding or thrombosis.
3-should have a complete blood count prior to treatment.
4-hemoglobin be reduced below
16g/dL and hematocrit to below
47%--->to avoid complications!
5-preoperative myelosuppressive treatment before dental treatment when blood counts are not controlled.
-general symptoms; pallor of the skin, palpebral conjunctiva and nail beds, dyspnea and easy fatigability.
1-may have oral ulcers (foul smelling), advanced periodontal disease, pericoronitis, and pulpal infections.
2-the infection must be cultured to determine the predominant organism.
3-patient should be placed on the appropriate combination of parenteral broad-spectrum antibiotics.
4-topical application of antibacterial mouth rinses helpful for ulcers.
5-a combination of topical neomycin, bacitracin and nystatin--->to reduce the risk of severe infection.
1-cervical lymphadenopathy, oral bleeding, gingival infiltrates, oral infections and oral ulcers.
2-should always weigh the risk of platelet transfusions against their benefit before recommending their use for treatment of oral bleeding.
3-topical treatment to stop gingival bleeding; removal of obvious local irritants and direct pressure.
-sign; asymptomatic enlargement of the cervical lymph node chains, without signs of infection, more than 1 lymph node chain is involved or a lymph node of 1 cm or greater in diameter persists for more than 1 month.
1-jaw lesions--->first evidence
2-pain, swelling, numbness of the jaws, epulis formation, or unexplained mobility of the teeth.
3-skull lesions--->more common than jaw lesions
4-hemorrhage and infection (bleeding from thrombocytopenia, abnormal platelet function, abnormal coagulation, or hyperviscosity)
5-if surgery is necessary--->obtain recent results of platelet count, bleeding time, PT and APTT.
Reference:
Prof. Nazih Syaaban's lecture notes