Post on 24-Dec-2015
The risks of any procedure can be increased by the
1. Health status o the patient
2. Complexity and duration of the case
3. Degree of invasiveness
4. Experience and skill of the operator
5. Addition of sedation or general anaesthesia
Risk StatusDefinitionApproach
INo overt systemic condition/sRoutine office care
May require sedation
IIMild /Moderate systemic diseases
Medically stableRoutine office care
Approach minor modification
IIISevere systemic condition/s
Medically fragile
Limited activity
Not debilitating
Emergency care
Medical consult
Modification
IVDebilitating systemic conditions
Constant threat to life
Emergency care
Medical consult
Care in hospital environment
VMorbid patientMaintain basic life support
Not expected to live
Status Classification for Dental Patients
American Society of Anesthesiologist (ASA)
Cardiovascular Diseases
Hypertension Angina Pectoris
Myocardial InfarctionInfective Endocarditis
Congestive Heart failure Previous Cardiac Bypass.
Previous Cerebrovascular AccidentPresence of Cardiac Peace Makers
Presence of prosthetic valve
Risk factors for cardiovascular disease
Smoking Excess alcohol Diabetes mellitus Hypercholesterolemia Lifestyle Obesity
It is important to assess Degree of compensation that the
patient has managed to achieve (signs and symptoms)
The efficacy of medication
Hypertension
No underlying UnderlyingPathological C. Pathological C.
95%Normal Blood pressure is 120/80 mm Hg
Dentist should have a baseline level
Hypertension
Primary SecondaryDental Tx for controlled hypertensive patient is safe except
patient with stages III - IV
Elective dental surgery on post-MI patient
Myocardial Infarction (MI)
Old Reports:
A 6 month waiting period for cardiac stabilityRecently: Pt. ( medically determined ) isn't at risk
Surgery as early as 6 weeks after the event, with protocol
Stressful situation may cause additional raise in BP (Stroke, MI)
Post –operative bleeding Interactions between patient`s
antihypertensive medication and other medications.
Complications in Hypertensive Patients
Consultation with the physician Patient assessment (risk factors)
Emergency kit (Nitrate & Oxygen))
Achievement of profound anesthesia Stress reduction measures (iv.
Sedation) Preoperative pain medication Vital sign monitoring (blood pressure,
heart rate)
Presence of Cardiac Peace MakersAvoid using ultrasonic and sonic instruments.
Presence of prosthetic valves or valve diseases:
Antibiotic prophylaxis is important before dental procedure.
Abnormality of the circulating level of thyroxine due to overproduction (hyperthyroidism) or under production (hypothyroidism)
Parathyroid hormones regulate the level of calcium in the plasma by acting on the kidney, gut and bone.
Hyperthyroidism may lead to loss of lamina dura around the teeth.
Thyroid disease may present as a goiter. Thyroid function should be stabilized before dental treatment.
PTH,
It is hypercalcemic, removing the calcium ions from bone and transferring them to circulating blood.
It increases the urinary elimination of phosphates by reducing their tubular reabsorption.
It contributes to maintaining an optimal calcemia by intervening in the kidney’s physiologic tubular reabsorption of calcium.
It plays an important role in the intestinal absorption of calcium in synergy with vitamin D
Adrenal Insufficiency
Acute adrenal insufficiency is associated with significant
morbidity and mortality owing to peripheral vascular
collapse and cardiac arrest. Therefore the operator should be aware of the clinical manifestations and ways of preventing acute adrenal insufficiency in patients with histories of primary adrenal insufficiency (Addison's disease) or secondary adrenal insufficiency (most often caused by use of exogenous glucocorticosteroids).
Management of the patient in an acute adrenal insufficiency crisis1. Terminate treatment.2. Summon medical assistance.3. Give oxygen.4. Monitor vital signs.5. Place the patient in a supine position.6. Administer 100 mg of hydrocortisone
sodium succinate (Solu-Cortef) intravenously for 30 seconds or intramuscularly.
Prolonged use of corticosteroids
Bone fragilityRenal deficiencyMetabolic disorders (blood sugar
metabolism)Water retentionInhibition bone resorption
Steroids act in three different ways that affect periodontal surgery;
1. They decrease inflammation and are useful in decreasing swelling and related pain.
2. They decrease protein synthesis and therefor delay healing.
3. They decrease leukocytosis and therefor reduce patient’s ability to fight infection
Whenever steroids are prescribed to patients for surgery, antibiotics should also be given.
Systemic complications of Diabetes Mellitus
Microvascular disease
Alteration in structure Cardiovascular disease
Thickening of vascular wall
Arteriosclerosis Stroke Nephrology Neuropathy Retinopathy
Diabetes-Induced Changes in Bone Formation
Inhibition of collagen matrix formation Alterations in protein synthesis Increased time for mineralization of osteoid Reduced bone turn over Decreased number of osteoblasts and
osteoclasts Altered bone metabolism Reduction in osteocalcin production
Surgical implant osteotomy
Blood clot formation
Bone resorption phase
Matrix formation phase
Bone deposition/ osteoid mineralization
Maintenance of osseointegration
Changes in wound healing proteins
Decreased number of osteoclast
Inhibition of collagen formation
Decreased number of osteoblast
Mineralization proteins reducedReduced bone turnover
Alterations in bone homeostasis
Change in diabetic status
Possible Risk Factors for the Diabetic Patient in periodontics Type of onset Age of patient Elevated blood glucose levels Regimen of glycemic control History of tooth loss due to periodontitis Poor insufficient wound healing history Extent of edentulous Smoking as a cofactor for implant failure
Hematological Disorders
Erythrocytic Disorders Polycythemia
(splenic enlargement, hemorrahges , thrombosis of peripheral veins).
Anemia
Leukocyte Disorders
Leukemia Platelet & Coagulation Anomalies
Problems with red blood cellsAnemia
Reduction in the oxygen-carrying capacity of the blood and is defined by a low value for hemoglobine
< 13.5 g/dl for men
< 11.5 g/dl for women
Severe Anemia
Hb < 7.0 g/dl
Poor Wound Healing
Bleeding disorders may be classified as
Coagulation disorders(hemophiliac A and B and von Willebrand's disease)
Thrombocytopenia (Platelet Disorders)(Thrombocytopenia is defined as a platelet count <100,000/mm 3 ).
Vascular Disorders
Laboratory Tests
Bleeding & Clotting T.
Hemoglobin Platelet Count Prothrombin Time
Partial thromboplastin time
Not sufficiently sensitive to be used as screening test.
Degree of anemia Platelet deficiency Plasma prothrombin level;
liver disease; defect in coagulation factor
Defect in coagulation factors Defects in capillary wall.
Normal bleeding time 2.5 – 8.0 minutesSevere bleeding more than 15 minutes Prothrombin time PT 11-14 seconds Partial thromboplastin time (PTT) 2.5-3.6
second
Normal Platelet Count 250.000 ± 100.000 cells/mm3
Spontaneous Bleeding 80.000 to 60.000 cells/mm3
Gingival irritation Gingival Inflammation
Liver Diseases
Liver is the site of production for most of the clotting factors, excessive bleeding during or after periodontal treatment may occur in patients with severe liver disease.
Many drugs are metabolized in the liver; thus liver disease alters normal drug metabolism.
Treatment recommendations for patientswith liver disease include the following
1. Consultation with the physician concerning current stage of disease, risk for bleeding, potential drugs to be prescribed during treatment, and required alterations to periodontal therapy.
2. Screening for hepatitis B and C.
3. Check laboratory values for prothrombin time and partial thromboplastin time.
Bone is the main calcium reservoir of the body, and maintenance of a proper serum calcium level is essential for homeostasis.
The most important calcium conserving organ in the body.
Kidney:
Patients with < 50% normal kidney function are at risk for surgery
Renal Dialysis Avoid drugs that are nephrotoxic or metabolized by
the kidney such as
Phenacetin, streptomycin, tetracycline Extraction of all questionable teeth Elimination all source of infection Good oral hygiene Prophylactic antibiotic coverage Provide treatment on the day after dialysis, when the
effects of heparinization have subsided.
Vitamin D is synthesized in the skin in response to ultraviolet light.
Vitamin D
Vitamin D is Vitamin D is hydroxylatedhydroxylated in the liver and in the liver and kidney to produce to active metabolite of kidney to produce to active metabolite of vitamin D, 1.25-dihydroxycholecalcifero vitamin D, 1.25-dihydroxycholecalcifero (1.25- DHCC), (1.25- DHCC),
Absorption of calcium from the small Absorption of calcium from the small intestine is accomplished by 1.25- DHCC.intestine is accomplished by 1.25- DHCC.
Vitamin D Deficiency
Osteomalacia
Contraindication for Dental Implant
Poor healing potential
Unmineralized osteoid with inadequate strength
Osteoporosis
A reduced weight per volume unite of bone, without a modified mineral to organic matrix ratio or any anomalies in either.
Osteoporosis
It is a negative balance of bone remodeling, resulting in reduction in the quantity of bone (number & diameter of trabecular bone) and a thinner cortex.
It occurs in postmenopausal women and elderly men, resulting in bone trabeculae that are scanty, thin, and without osteoclastic resorption.
Prosthetic Joint ReplacementThe main treatment consideration for
patients with prosthetic joint replacements relates to the potential need for antibiotic prophylaxis before dental therapy.
Antibiotic Prohylaxices
Patient CharacteristicsDrug Regimen
Patients not allergic to penicillinsCephalexin, cephradine, oramoxicillin: 2 g orally1 hour before dental procedure
Patients allergic to penicillinsClindamycin: 600 mg orally1 hour before dental procedure
Patients not allergic to penicillins but unable to take oral medication
Cefazolin 1 g or Ampicillin 2 g intramuscularly or intravenously 1 hour before dental procedure
Patients allergic to penicillins and unable to take oral medications
Clindamycin 600 mg intralivenously 1 hour before dental procedure (must be diluted and injected slowly)
Medications of Interest to periodontal surgery
Anticoagulant Medications Bisphosphonates Immunosuppressive Medications Rheumatoid Arthritis
Patients on Anti-Coagulant Drugs
Heparin Bishydroxycoumarin (Dicumarol) Warfarin sodium (Coumadin) Phenindione derivatives Cyclocumarol Ethyl biscoumacetate Aspirin
Warfarin
Warfarin is administrated orally Action up to 6 daysManagement of:
Atrial fibrillation ( as thromboembolic prophylaxis)
Deep vein thrombosis
Prevention of embolisation secondary to MI
After prosthetic heart valve replacement
The therapeutic efficacy is monitored using the International Normalized Ratio (INR)
INR =Patient's Prothrombin Time
Normal Prothrombin Time
Normal 1.0-1.3
During anticoagulant therapy, 2.5-3.0
Pt. with prosthetic heart valve 3.0-4.5
Test to Monitor Oral Anticoagulants
Aspirin
0,5 to 1 mg /kg antiplatelet effect 5 – 10 mg/kg antipyretic effect 30 mg/kg anti-inflammatory response
Bisphosphonates
Laboratory Risk Assessment
C-telopeptides (CTx) (fragments of collagen that are
released during bone remodeling and turnover)
Immunosuppressive Medicated
Immunosuppressed patients have impaired host defenses as a result of an underlying immunodeficiency or drug administration (primarily related to organ transplantation or cancer chemotherapy).
Glucocorticoids (Prednisone)
Antibodies
Cytostatics (chemotherapeutic agents)
Immunophilins (cyclosporine)
Immunosuppressed individuals are at greatly increased risk for infection, and even minor periodontal infections can become life threatening if immune suppression is severe.
Chemotherapy is often cytotoxic to bone marrow, destruction of platelets and red and white blood cells results in thrombocytopenia, anemia, and leukopenia
Radiation Therapy
Most severe among the resulting oral complications
is osteoradionecrosis (ORN).
Decreased vascularity renders the bone less capable of resolving trauma or infection. Such events may cause severe destruction of bone. The risk of ORN continues for the remainder of the patient's life and does not decrease with time
Flap surgery or extraction of teeth after radiation may lead to ORN.
Hyperbaric oxygen therapy is frequently required for complete resolution.
Pregnancy
Second trimester is the safest time Do not perform long and stressful
procedures Short appt. Changing position from time to time
to avoid hypotension. Fully reclined position should be
avoided if possible.