Dental Management of Medically Compromised Ayko Nyush. This ebook is uploaded by James W. Little, DMD, MS Craig S. Miller. FOREWORD I t is now 5 years since the sixth edition of Dental Management of the Medically Compromised Patient was published. The number. Journal section: Medically compromised patients in Dentistry. Publication Types: The dental management of patients with special needs, whether.

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Definition: It is the management of patients in whom the dental treatment may need modification according to their medical condition. Preoperative Management. with oral complaints that may be seen in general dental practice. Space precludes . Table 1 Management of the medically compromised patient and recent controversies. Medical ARONJ_-_Suzuki_& (accessed July ). Request PDF on ResearchGate | Management of the Medically Compromised Dental Patient | American Heart Association (AHA) Guidelines for Antibiotic.

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To evaluate any source of infection that may compromise successful medical or surgical therapy and restore optimal oral health and function. Full mouth intra-oral radiographs plus panoramic radiograph 2. Panoramic radiograph only if edentulous or not able to take intraoral films 3.

Thorough medical and dental history, including medications documented on the dental chart. Physician consultation to corroborate medical history and coordinate dental and medical care. Initiate preventive therapy. Arrange treatment. Arrange follow-up. Prosthetic heart valves 2. This knowledge includes an under- standing of medical conditions and compromised states and is necessary to help prevent, minimize, and alert cli- nicians to possible adverse side effects potentially associ- ated with procedures and drugs used in dentistry.

Care of the medically compromised patient often is complicated, requiring specialists. However, occurrence of compromised patients is so common that practitioners and students must know how to recognize and prevent problems associated with dental management, and to use consultations and referrals appropriately.

Dental management in patients with hypertension: challenges and solutions

This updated, revised, and expanded text recognizes and supplies this type of information with practical and organized over- views of diagnosis and management. The 30 chapters, now in color, are presented in 9 logical parts that enhance user-friendly utility. An appendix on alternative and com- plementary medicine has also been added. Although the main focus is on the management of medically compromised patients having dental proce- dures, the text effectively includes a medical overview of each disease entity, including etiology, signs and symp- toms, pathophysiology, diagnoses, treatment, and prog- nosis.

Therefore it also serves as a mini-text on common medical diseases and conditions. Because tobacco use is the most common cause of preventable deaths in the United States more than , each year , a chapter on this topic has been added.

In its present format, it serves as both a quick reference and a somewhat in-depth resource for this critical interface of medicine and den- tistry. It will help ensure high standards of care and help reduce the occurrence of adverse reactions by improving knowledge and encouraging judgment in the manage- ment of at-risk patients.

There- fore the usefulness of this excellent updated, comprehen- sive text as a reference for students and practitioners is evident. Sol Silverman, Jr.

A number of major changes have been made in the seventh edition. The chapters have been reorganized and placed under topic headings to streamline the text. For example, the following chapters are placed under the topic heading of Cardiovascular Disease—Chapter 2: Infective Endocarditis Prophylaxis; Chapter 3: Hypertension; Chapter 4: Ischemic Heart Disease; Chapter 5: Cardiac Arrhythmias; and Chapter 6: Heart Failure. Three new chapters have been added—Chapter 8: Smoking and Tobacco Use Cessation; Chapter 9: Tuberculosis; and Chapter Sleep-Related Breathing Disorders.

Chap- ters that had previously been one combined chapter have been split into two separate chapters for better readabil- ity. This includes Chapter Disorders of Red Blood Cells and Chapter Disorders of White Blood Cells, and Chapter Psychiatric Disor- ders.

A new appendix devoted to the use of alternative and complementary drugs in dentistry has been added— Appendix E: Alternative and Complementary Drugs. Chapters 2 and 3 Infective Endocarditis and Cardiac Conditions Associated With Endocarditis from the sixth edition have been combined into one new chapter, Chapter 2: Infective Endocarditis Prophylaxis, which incor- porates the latest guidelines for the prevention of bacte- rial endocarditis from the American Heart Association.

Neuro- logic Disorders, and the use of bisphosphonates and its complications are discussed in Chapter Cancer and Oral Care of the Patient.

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The purpose of the book remains the same—to give the dental provider an up-to-date, concise, factual refer- ence describing the dental management of patients with selected medical problems.

The more common medical disorders that may be encountered in a dental practice continue to be the focus. This book is not a comprehen- sive medical reference, but rather a book containing enough core information about each of the medical con- ditions covered to enable the reader to recognize the basis for various dental management recommendations. In particular, the text is intended to give the dental provider an understanding of how to ascertain the severity and stability of common medical disorders and make dental management decisions that afford the patient the utmost health and safety.

Continued emphasis has been placed on the medica- tions used to treat the medical conditions covered in this seventh edition. Dosages, side effects, and drug interac- tions with agents used in dentistry—including those used during pregnancy—are discussed in greater detail. Emphasis also has been placed on having contemporary equipment and diagnostic information to assess and monitor patients with moderate to severe medical disease. Our sincere thanks and appreciation are extended to those many individuals who have contributed their time and expertise to the writing and revision of this text.

James W. Little Donald A. Falace Craig S. Miller Nelson L. Rhodus ix 4. Dental Management: A Summary T his table presents the more important factors to be considered in the dental management of medically compromised patients.

Each medical problem is outlined according to potential problems related to dental treatment, oral manifestations, preven- tion of these problems, and effects of complications on dental treatment planning. This table has been designed for use by dentists, dental students, graduate students, dental hygienists, and dental assistants as a convenient reference work for the dental management of patients who have medical diseases dis- cussed in this book.

DM-1 5. Dental procedures that involve the manipulation of gingival tissues or the periapical region of teeth or perforation of the oral mucosa can produce a bacteremia.

Although it is unlikely that a single dental procedure—induced bacteremia will result in infective endocarditis IE , it is remotely possible that it can occur. Patients with mechanical prosthetic heart valves may have excessive bleeding following invasive dental procedures as the result of anticoagulant therapy.

Routine delivery of dental care to a patient with severe uncontrolled hypertension could result in a serious outcome such as angina, myocardial infarction, or stroke. Stress and anxiety related to the dental visit may cause an increase in blood pressure, leading to angina, myocardial infarction, or stroke. In patients taking nonselective beta blockers, excessive use of vasoconstrictors can potentially cause an acute elevation in blood pressure.

Some antihypertensive drugs can cause oral lesions or oral dryness and can predispose patients to orthostatic hypotension. Cephalexin should not be used in individuals with a history of anaphylaxis, angioedema, or urticaria with penicillins. If treatment becomes necessary before 9 days have passed, select one of the alternative antibiotics for prophylaxis.

The stress and anxiety of a dental visit could precipitate an anginal attack, myocardial infarction, or sudden death. For patients who are taking a nonselective beta blocker, the use of excessive amounts of epinephrine could precipitate a dangerous elevation in blood pressure. Patients who are taking aspirin or other platelet aggregation inhibitor may experience excessive bleeding.

Questions may arise as to the necessity of antibiotic prophylaxis for patients with a history of coronary artery bypass graft, balloon angioplasty, or stent. Patients may have some degree of heart failure. If the patient has a pacemaker, some dental equipment may potentially cause electromagnetic interference. In patients who are taking a nonselective beta blocker, excessive amounts of epinephrine may cause a dangerous elevation in blood pressure.

Patients who are taking aspirin or another platelet aggregation inhibitor or Coumadin may experience excessive postoperative bleeding. Questions may arise as to the necessity of antibiotic prophylaxis for patients with a history of CABG, balloon angioplasty, or stent. Also, bleeding may be excessive because of the use of aspirin, other platelet aggregation inhibitors, or Coumadin. Management may include establishment of an IV line; sedation; monitoring of electrocardiogram, pulse oximeter, and blood pressure; oxygen; cautious use of vasoconstrictors; and prophylactic nitroglycerin.

Excess bleeding is usually manageable through local measures only; discontinuation of medication is not recommended. The stress and anxiety of dental treatment or excessive amounts of epinephrine may induce life-threatening arrhythmias in susceptible patients. Patients with existing arrhythmia are at increased risk for serious complications such as angina, myocardial infarction, stroke, heart failure, or cardiac arrest.

Patients with a pacemaker or a defbrillator are at risk for possible malfunction caused by electromagnetic interference from some dental equipment; some question about the need for prophylactic antibiotics may arise. Patients who are taking digoxin are at risk for arrhythmia if epinephrine is used; digoxin toxicity is also a potential problem. Providing dental treatment to a patient with symptomatic or uncontrolled heart failure may result in worsening of symptoms, acute failure, arrhythmia, myocardial infarction, or stroke.

Elective dental care should be deferred; if care becomes necessary, it should be provided in consultation with the physician. Management may include establishment of an IV line; sedation; monitoring of electrocardiogram, pulse oximeter, and blood pressure; oxygen; and cautious use of vasoconstrictors. For patients who are taking Coumadin, the INR should be 3. For patients who are taking digoxin, avoid the use of epinephrine because of the increased risk of inducing arrhythmia; be observant for signs of digoxin toxicity e.

Heart failure is due to an underlying condition such as coronary artery disease or hypertension that may require management considerations. The use of epinephrine in patients who are taking digoxin may cause arrhythmia. Tuberculosis may be contracted by the dental health care worker from an actively infectious patient. Patients and staff may be infected by a dentist who is actively infectious. Have the patient bring medication inhaler to each appointment, and prophylax with an inhaler prior to each appointment for persons with moderate to severe persistent asthma.

Questionable history of adequate treatment 2. Lack of appropriate medical supervision since recovery 3. Patients with untreated obstructive sleep apnea are at increased risk for hypertension, stroke, arrhythmia, myocardial infarction, and diabetes.

Hepatitis may be contracted by the dentist from an infectious patient.

Patients or staff may be infected by the dentist with active hepatitis or who is a carrier. With chronic active hepatitis, the patient may have chronic liver dysfunction, which may be associated with a bleeding tendency or altered drug metabolism.

Because most carriers are undetectable by history, all patients should be treated with the use of standard precautions see Appendix B ; risk may be decreased by the use of hepatitis B vaccine.

Age at time of infection type B uncommon at younger than 15 years of age 2. Source of infection if food or water, usually type A or E 3. If blood transfusion related, probably type C 4. If type is indeterminate, assay for hepatitis B surface antigen HBsAg may be considered. In patients who are being treated with steroids, stress may lead to serious medical problems.

Bleeding tendency 2. Hypertension 3. Anemia 4. Intolerance to nephrotoxic drugs metabolized by the kidney 5. Hepatitis active or carrier 7. Bacterial endocarditis 8. Syphilis may be contracted by the dentist from an actively infectious patient. Patients or staff may be infected by the dentist who has syphilis.

Consultation with physician. Delay dental treatment for at least 4 hours following dialysis to avoid heparin effects potential for excessive bleeding ; best to perform dental treatment on the day following dialysis.

Avoid drugs metabolized by kidney or nephrotoxic drugs. AHA does not recommend antibiotic prophylaxis for invasive dental procedures. Avoid placing blood pressure cuff on the arm containing the shunt used for dialysis. In uncontrolled diabetic patients: Infection b. Poor wound healing 2. Insulin reaction in patients treated with insulin 3. Appropriate treatment and follow-up care should be provided. Inability to tolerate stress 2. Delayed healing 3.

Susceptibility to infection 4. Thyrotoxic crisis thyroid storm may be precipitated in untreated or incompletely treated patients with thyrotoxicosis by: Trauma c. Surgical procedures d. Stress 2. Patients with untreated or incompletely treated thyrotoxicosis may be very sensitive to actions of epinephrine and other pressor amines; thus, these agents must not be used; once the patient is well managed from a medical standpoint, these agents may be administered. Thyrotoxicosis increases the risk for hypertension, angina, MI, congestive heart failure, and severe arrhythmias.

Give 25 mg hydrocortisone every 8 hours for 24 to 48 hours postoperatively. Untreated patients with severe hypothyroidism exposed to stressful situations such as trauma, surgical procedures, or infection may develop hypothyroid myxedema coma.

Untreated hypothyroid patients may be highly sensitive to actions of narcotics, barbiturates, and tranquilizers. Acute suppurative—Patient has acute infection, antibiotics 2.

Subacute painful—Period of hyperthyroidism 3. Subacute painless—Up to 6-month period of hyperthyroidism 4. Usually none 2. Levothyroxine suppression following surgery and radioiodine ablation is usual treatment for follicular carcinomas. Patient may have mild hyperthyroidism. May be sensitive to actions of pressor amines.

See above for uncontrolled disease.

Hard, painless lump in thyroid b. Dominant nodule in multinodular goiter c. Hoarseness, dysphagia, dyspnea d. Cervical lymphadenopathy e.

See summary of Chapter Patients with anaplastic carcinoma have a poor prognosis and complex dental procedures are usually not indicated. Dental procedures could harm the developing fetus via: Radiation b. Drugs c. Supine hypotension in late pregnancy 3. Poor nutrition and diet can affect oral health.

Transmission of drugs to infant via breast milk 5. Transmission of infectious agents to dental personnel and patients includes: Hepatitis B virus HBV c. Hepatitis C virus HCV d. Epstein-Barr virus EBV e. Cytomegalovirus CMV 2. To date, no dental health care workers have been infected with HIV through occupational exposure; six patients may have been infected by an HIV-infected dentist; thus, risk of HIV transmission in the dental setting is very low, but the potential exists. The second trimester and most of the third trimester are the best times for elective treatment.

Transmission of infectious agents to dental personnel and patients includes the following: HIV b. Hepatitis B virus c. Hepatitis C virus d. Epstein-Barr virus e. Cytomegalovirus 2. To date, with the exception of possible transmission by a Florida dentist: HIV has not been found to be transmitted to patients in the dental setting. No dental health care workers have been HIV infected through occupational exposure. Patients with decreasing CD4 lymphocytes may be thrombocytopenic and hence potential bleeders.

Transmission of infectious agents to dental personnel and patients: To date, HIV has not been found to be transmitted to patients in the dental setting possible exception of six patients who may have been infected by a Florida dentist ; no dental health care workers have been HIV infected through occupational exposure; however, HBV and HCV have been transmitted to patients or dental health care workers on a number of occasions in the dental setting.

Patients may be bleeders because of thrombocytopenia. Severe reaction following administration of agent to patient who is allergic to agents such as: Drugs b.

Local anesthetic c. Nonemergency; edematous swelling of lips, cheek, etc.

Little and Falace's Dental Management of the Medically Compromised Patient

Most patients who say they are allergic will describe a fainting episode or a toxic reaction. If an allergic reaction has occurred, identify the type of anesthetic used, and select one from various chemical groups. Refer to allergist for provocative dose testing, or b. Use diphenhydramine Benadryl with epinephrine 1: High rate of infection, but the role of transient dental bacteremias that cause these infections has not been established.

Infection from suppression of immune response by the following: Cyclosporine b. Azathioprine c. Prednisone d. Antithymocyte globulin e. Antilymphocyte globulin f.The text on each disease includes incidence and prevalence, aetiology, pathophysiology and complications, signs, symptoms and laboratory findings, medical management, and dental management and oral manifestations.

Epstein-Barr virus e.

Always err on the side of hyperglycaemia; ensure the patient has breakfast and lunch. This leads to vasodilatation and bronchial constriction and thus: Complications Complications of peptic ulcers include: Some of these include: Asthma is a world wide problem. Dental treatment should be completed well before the transplant operation. Commonly used analgesics are the non-narcotic analgesics.