Management of medically compromised patients in dental practiceMedical history•Standard format for recording results of history and physical examinations•Biographic data•Chief complain and its history.•Medical history•Social and family medical history•Review of systems•Physical examination•Laboratory and imaging results.

Base line health history data base•Past hospitalizations, operations, traumatic injuries, and serious illness.•Recent minor illnesses or symptoms.•Medications currently or recently in use and allergies(particularly drug allergies.•Description of health related habits or addictions such as the use of ethanol, tobacco, amount and type of daily exercise.•Date and result of last medical checkup and results.

•Common health conditions to inquire about verbally or in a health questionnaire•Allergies to antibiotics or local anesthetics.•Angina.•Anticoagulant use.•Asthma.•Bleeding disorders.•Breast feeding.•Corticosteroid use.•Diabetes.•Heart murmurs.•Hepatitis.•Hypertension‘.•Implanted prosthetic devices.•Lung diseases.•Myocardial infarction(heart attack).•Osteoporosis.•Pregnancy.•Renal disease.•Rheumatic heart disease.•Seizure disorder.•Sexually transmitted disease.•Tuberculosis.

Routine review of head, neck and maxillofacial region•Constitutional: fever chills sweets, weight loss, fatigue, malaise, loss of appetite.•Head: Headache, dizziness, fainting, insomnia.•Ears: decreased hearing, tinnitus(ringing),pain.•Nose and sinuses: rhinorrhea, epistaxis, problems breathing through nose, pain, change in sense of smell.•TMJ: pain noise, limited jaw motion, locking.•Oral: dental pain, sensitivity, lip or mucosal sores, problems chewing, problems speaking, bad breath, loose restoration, sore throat, loud snoring.•Neck: difficulty swallowing, change in voice, pain, stiffness.

Review of cardiovascular and respiratory systems•Cardiovascular review•Chest discomfort on exertion when eating or at rest. Palpitations, fainting, ankle edema, shortness of breath(dyspnea) on exertion dyspnea on assuming supine position(orthopnea or paroxysmal nocturnal dyspnea),postural hypotension, fatigue, leg muscle cramping.•Respiratory review:•Dyspnea with exertion, wheezing, coughing, excessive sputum production, coughing up blood (hemoptysis).

•Physical examination before oral surgery and maxillofacial surgery

Inspection•Head and face : general shape, symmetry, hair distribution.•Ear: normal reaction to sounds(otoscopic examination if indicated)•Eye: symmetry, size, reactivity of pupil, color of sclera and conjunctiva, movement, test of vision.•Nose: septum, mucosa, patency•Mouth: Teeth, mucosa pharynx, lips and tonsils.•Neck: size of thyroid gland, jugular venous distention.

Palpation•TMJ: crepitus•Tenderness.•Paranasal; pain over sinuses.•Mouth: salivary glands, floor of mouth, lips, muscles of mastication.•Neck: thyroid gland size, lymph nodes.

Percussion•Paranasal: resonance over sinuses (difficult to assess)•Mouth: teeth.

Auscultation•TMJ: clicks, crepitus•Neck: carotid bruits.

Management of patients with compromising medical conditionsPatients with medical conditions sometimes require modifications of their perioperative care when oral surgery is planned.General anxiety-reduction protocolBefore appointment•Hypnotic agent to promote sleep on night before surgery. (optional)•Sedative agents to decrease anxiety on morning of surgery (optional)•morning appointment and schedule so that the reception room time is minimized.

During appointmentNon pharmacologic means of anxiety control•Frequent verbal reassurances•Distracting conversation•No surprises(clinician warn patient before doing anything that could cause anxiety)•No unnecessary noise.•Surgical instruments out of patients sight•Relaxing back ground

Pharmacologic means of anxiety control•Local anesthesia of sufficient intensity and duration•Nitrous oxide•Intravenous anxiolytics

After surgery•Instructions for post operative care•Patient information about on expected postsurgical sequel( e.g.: swelling or minor oozing of blood)•Further reassurance•Effective analgesics•Patient information on who can be contacted when problems arise•Telephone call to patient at home during evening after surgery to check whether any problem exist

Angina pectoris•Progressive narrowing or spasm(or both) of one more of the coronary arteries.•In case of increased O2 demand(e.g. excretion or anxiety, coronary arteries are not able to supply O2 carrying blood sufficiently.•Myocardium become ischemic and produce pain that radiates to left arm and even in mandibular region.•Preventive measures began with taking a careful history of the patient’s angina.•Ambulatory oral surgery is safe with proper precautions

If the patient’s angina arises only during moderately vigorous exertion and respond readily to rest or nitroglycerin and no recent increase has occurred.•Patient’s physician should be consulted before elective surgery1.If angina episodes occur with only minimum exertion,2.if several doses of nitroglycerin are needed to relief chest pain or 3.if the patient has unstable angina(i.e.; angina occurs at rest, worsen in frequency, duration or severity and response to medication or diminished activity,

•Once surgery is decided O2 demands should be lowered. Increase in O2 demand primarily occur due to anxiety. •Anxiety reduction protocol should therefore be used. Profound local anesthesia is the best means to decrease anxiety although epinephrine may be controversial in angina pectoris patients.•Patient should be given only 4ml local anesthetics with 1:100,000 conc. epinephrine for a total adult dose of 0.04mg in any 30 min period.•Management of patients with history of angina pectoris:1.Consult patient physician2.Use an anxiety reduction protocol.3.Have nitroglycerin tablets or spray readily available. Use NG premedication if indicated.4.Profound Local anesthesia.5.Consider using nitrous oxide.6.Monitor vital signs.7.Consider limitation of epinephrine amount (0.04mg)8.Verbal contact with patient during procedures.

•Myocardial infarction: MI•Occurs when ischemia causes myocardial cellular dysfunction and death. •MI occurs when an area of coronary artery narrowing has a clot form that blocks all or most blood flow.•The infarcted area become non-functional and necrotic, and surrounded by reversible ischemic myocardium that serves as a nidus for dysrhythmia.•During early hours and weeks after MI:•If thrombolytic treatment is unsuccessful, treatment consist of :1.Limiting myocardial work repair2.Increase myocardial O2 supply3.Suppressing production of dysrhythmia4.Pace maker

If patient survives the early weeks after MI:

Necrotic area gradually replaced by scar tissue, which is unable to contract or properly conduct signals. Management of patients with myocardial infarction:1.If invasive surgery is needed before 6 month since the MI consult the patient physician. 2.Check if the patient is taking anticoagulant.3.Use an anxiety reduction protocol.4.Have nitroglycerin tablets or spray readily available. Use NG premedication if indicated.5.Supplemental O2 (optional)6.Profound Local anesthesia.7.Consider using nitrous oxide.8.Monitor vital signs.9.Consider limitation of epinephrine amount (0.04mg)10.Consider referral to maxillofacial surgeon.

Cerebrovascular accident(stroke):1.Anticoagulant2.Antihypertensive

Dysrhythmias:1.Anticoagulant2.Pacemaker Avoid electrical devices near patientsa)Avoid electro surgeryb)Microwaves

•Congestive heart failure hypertrophic cardiomegaly(CHF):•Occur when a diseased myocardium is unable to deliver the COP demanded by the body that leads to: generalized weakness.•As the heart dilates it becomes less efficient pump causing blood backup into:1.Pulmonary vascular bed that leads to pulmonary edema2.Hepatic vascular bed that leads to hepatic dysfunction3.Mesenteric vascular bed that leads to compromised intestinal nutrient absorption.4.Impaired renal clearance of excess fluids that leads to vascular overload.

Symptoms of CHF1.Orthopnea2.Paroxysmal nocturnal dyspnea3.Ankle edema4.Weight gain5.Dyspnea on exertion.

Management of patient with congestive heart failure (CHF)•Defer treatment until patient’s physician believes treatment is possible•Consider supplemental O2•Avoid supine position•Consider referral to maxillofacial surgeon.

Pulmonary problemsI.Asthma:•It involves episodic narrowing of inflamed small airways which produces wheezes and dyspnea as a result of chemical, infectious, immunologic, emotional stimulation or combination.•Careful history taking to differentiate between asthma and allergic rhinitis.

During history taking questions should concentrate on:1.Precipitating factors2.Frequency3.Severity of attacks(considered severe if hospital admission was needed)4.Response to medications

5.Special question about aspirin allergy, because of increased NSAIDs allergy in those asthma patients.

Medical treatment for asthma patients:According to frequency, severity, and causes:a.Theophylline bronchodilator for sever asthma.b.Cromolyn protect against attacksc.Epinephrine aerosol if wheezing occur

•If infection or wheezes are present elective surgery should be deferred.•Anxiety reduction protocol•Ask physician about the possibility of augmenting corticosteroids in the perioperative period if a major operative procedure is indicated.•Nitrous oxide is safe and indicated for anxiety triggered asthma. •Patient’s own inhaler should be with the patient during appointment.•Avoid using NSAIDs. •Management of patient with Asthma1.Defer treatment until asthma is well controlled and there is no infection2.Check presence of wheezes before procedures or sedation3.Use anxiety reduction protocol, including nitrous oxide4.Consult patient’s physician about possible use of Cromolyn sodium5.Provide prophylaxis for adrenal insufficiency if the patient is chronically taking corticosteroids6.Keep bronchodilator containing inhaler ,Injectable epinephrine or theophylline during appointment should be easily accessible7.Avoid use of non steroidal anti inflammatory drugs (NSAIDs)

Chronic obstructive pulmonary disease (COPD)•It is an obstructive and restrictive disease(formerly emphysema and bronchitis) usually caused by long term exposure to pulmonary irritant e.g.: Tobacco.Airways become:1.Inflamed 2.Disrupted3.Loss their elasticity4.Obstructed because :a.Mucosal edemab.BronchospasmCOPD patients usually become dyspneic during mild to moderate exertion.Chronic cough with thick secretionFrequent respiratory tract infectionBarrel shape chest.Purse lips to breath.Audible wheezes during breathing.

Medical treatment:a.Bronchodilatorsb.Corticosteroids in severe cases.c.Supplemental oxygen.

Dental management:1.Additional corticosteroids supplement before major surgery in corticosteroid patients.2.Sedative hypnotics and narcotics are contraindicated because they depress respiration3.Upright position in dental chair to handle pulmonary secretion.4.Avoid supplemental oxygen unless patient’s physician advice . Y?

Because COPD patient is used to high CO2 levels and comes to depend entirely on low O2 arterial level to stimulate respiration.

So if O2 is administrated the hypoxia based respiratory mechanism is removed and the patient’s respiratory rate may be artificially slowed.Management of patient with renal insufficiency and patients receiving hemodialysis1.Avoid using drugs that depend on renal metabolism or excretion. Modify the dose if such drugs are necessary. 2.Avoid the use of nephrotoxic drugs such as non-steriodalanti-inflammatory drugs.(NSAIDs)3.Defer dental care until the day after dialysis has been given. This allows heparin used during dialysis to disappear.4.Consult the patient’s physician about the use of prophylactic antibiotic.5.Monitor blood pressure and heart rate.6.Look for signs of secondary hyperparathyroidism. (metabolic radiolucencies)7.Screen patient for hepatitis B.

Management of patient with renal transplant1.Consult physician before start of treatment.2.Avoid nephrotoxic drugs3.Consider using supplemental corticosteroids.4.Monitor blood pressure.( because these patients suffer from hypertension)5.Screen patient for hepatitis B.6.Watch the presence of cyclosporine A induced gingival hyperplasia. Emphasize importance of oral hygiene.7.Consider use of prophylactic antibiotic Because these patients receive immunosuppressive drugs).

Management of patient with hypertensionMild to moderate hypertension (systolic>140mmhg, diastolic>90mmhg)1.Monitor the patient blood pressure when given local anesthesia with epinephrine >0.04 mg in a single visit.2.Use anxiety reduction protocol.3.Avoid rapid posture changes in patients taking vasodilatation drugs.4.Avoid administration of sodium containing intravenous solutions.

Severe hypertension(systolic>200mg HG ; diastolic >110mmHG)1.Defer elective dental treatment until hypertension is controlled.2.Consider referral to oral and maxillofacial surgeon for emergent problems.

Management of patients with hepatic insufficiency1.Check the cause, screen for HepB.2.Avoid drugs requiring hepatic metabolism or excretion, if their use is necessary modify the dose.3.Screen patients with severe liver disease for bleeding disorders by using tests for determining :a.Platelet countb.Prothrombin timec.Partial thromboplastin timed.Bleeding time4.Avoid situations in which the patient swallow large amounts of blood.