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Dental Management for MedicallyCompromised Patients

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Risk Assessment?

Can we provide routine dental treatment to this patient withoutendangering their (or our) health and well being?

Yes. No problems are anticipated, and treatment can be deliveredin the usual manner. (Benefit > Risk)

Yes, but potential problems may be anticipated, and modificationsin the delivery of treatment are necessary. (Benefit > Risk)

No. Potential problems exist that are serious enough to make itinadvisable to provide elective dental treatment. (Risk > Benefit)

You may not be able to completely eliminate the risk of an adverse eventoccurring during dental treatment or as a result of dental treatment,

however, our goal is to reduce that risk as much as possible The issue then becomes whether the remaining risk is acceptable and

that having the dental treatment is of more benefit than not having it

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Dental Practice

Syncope 15,407 Mild Allergic Reaction 2,583 Angina Pectoris 2,552 Postural Hypotension 2,475 Seizures 2,195 Asthmatic Attack 1,392 Hyperventilation 1,326 Epinephrine Reaction 913

Insulin Shock 890 Cardiac Arrest 331 Anaphylaxis 304 Myocardial Infarction 289

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Medical Risk Assessment Begins withIdentification of Medical Problems

Medical history (questionnaire/interview)

Physical examination (general survey, face,eyes, skin, etc)

Laboratory tests (screening, confirmation)

Medical consultation (physician, dentist,pharmacist)

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Why take a medical history?

Many medical problems and/or drugs canaffect or influence the provision of dentalcare.

Examples: Heart disease (infection, bleeding, drug interactions,

cause an MI or angina, oral lesions)

Allergies (reactions to local anesthetics, antibiotics,analgesics, latex)

Diabetes (infection, hypoglycemia, periodontaldisease)

Bleeding disorders; drug induced or genetic(abnormal hemostasis)

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RHEUMATIC HEART DISEASE

Rheumatic heart disease (RHD) is aconsequence of acute rheumatic fever (ARF).The risk of RHD is greater with repeatedepisodes of ARF. While ARF usually occursbetween 5 and 15 years of age, it can alsooccasionally occur in adulthood. RHD isparticularly associated with damage to the

valves of the heart. ARF is caused by infectionwith the Group A Streptococcus bacterium.

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RHEUMATIC HEART DISEASE

It is an acute inflammatory condition, due to strep. Pharngitisinfection following sore throat, result in scaring &calcification of valves followed by valvular stenosis.

While rheumatic heart disease (RHD) may develop after asingle bout of acute rheumatic fever (ARF), it is typicallyassociated with recurrent episodes of ARF. ARF usually occurs

during childhood between the ages of 5 and 15 years. RHD candamage any part of the heart including the valves, the lining ofthe heart or the heart muscle, but more often damages theheart valves, especially those on the left side of the heart.

Stopping episodes of recurrent ARF can prevent rheumaticheart disease. ARF is caused by infection with the Group

AStreptococcus (GAS) bacterium. This usually involves GASinfection in the throat (pharyngitis) or strep throat. There isongoing debate about whether ARF may also occur with aGroup AStreptococcus skin infection (impetigo, pyoderma).

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Symptoms of RHD

RHD does not always cause symptoms. When it does,the symptoms may include:

Chest pain Heart palpitations Breathlessness on exertion Breathing problems when lying down (orthopnoea) Waking from sleep with the need to sit or stand up

(paroxysmal nocturnal dyspnoea) Swelling (oedema)

Fainting (syncope) Stroke Fever associated with infection of damaged heart

valves.

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Dental management.

1. Medical consultation.

2. Prophylactic antibiotic.

3. Mild tranquilizers (2-5 diazepam).

4. Short dental appointment.

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Always have your regular penicillin injectionsThe most important thing to know if you havehad rheumatic fever is that you must haveregular penicillin injections to prevent getting

rheumatic heart disease.

The best way to stop another episodeof rheumatic fever is to have regular penicillininjections. This will be prescribed by the doctor

and is likely to be- every 28 days for 10 years or until a person is 21

years old.

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- given in the thigh or bottom- the injection can be painful for some but in timeit becomes easier to deal with- are given by an aboriginal health worker, nurse

or doctor Suffering rheumatic fever in the past increases

the risk of developing bacterial endocarditisafter a dental procedure.

If a dentist is aware of this they will give a courseof preventive antibiotics, before any procedurethat involves gum bleeding e.g. professionalcleaning, extraction, injections.

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Dental management.

It is in a large part the dentists responsibilityto manage the patient with valsular heartdisease by treatment with Sulfonamides. It isthought that prophylactic premedication withsulfathiazole may prevent the individual withvalvular heart disease from developing asubacute bacterial endocarditis.