Medically Compromised Patients

Transcription

1 Medically Compromised Patients (Part I) Ra ed Salma BDS, MSc, JBOMFS, MFDRCSI

2 All information in this file is updated till April, 2014

3 Cardiovascular Diseases

4 I. Ischemic Heart Disease (IHD) 1. Angina Pectoris Definition: - Episodes of chest pain caused by myocardial ischemia secondary to CAD Pain characteristics: - Pain described as heaviness (fullness, pressure, tightness) in the mid-thorax (retrosternal) area that may radiate to jaw/teeth, arm/shoulder &/or back

5 Precipitating factors: 1. Physical exertion (esp. in cold weather) 2. Emotional stress (anger, anxiety & fear) 3. Pain Catecholamines Increase work load on the heart

6 Types: 1. Stable angina: angina on exertion & relieved by rest &/or GTN (glyceryl trinitrate usually sublingual) 2. Unstable angina (acute coronary syndrome): sudden angina at rest medical emergency 3. Syndrome X: normal coronary arteries (functional?) 4. Prinzmetal angina (Vasospastic): coronary arteries spasm

7 General management: 1. Medical therapy: mainly GTN 1. Surgical therapy if frequent or not responding to drugs: - Angioplasty: Balloon catheter +/- stent - Coronary Artery Bypass Graft (CABG)

8 Dental management of angina patients 1. Stable angina: - Minor procedures under LA only - Stress reduction protocol - Pre-sedate with oral diazepam (not essential) - If attacks > once/week prophylactic sublingual GTN (use patient s own drug) - Check other diseases (DM, HTN, HF) - LA with adrenaline is safe (except in CABG)

9 2. Unstable angina: - Defer elective dental treatment until physician agree, if so teat as below - Emergency dental treatment: * Best hospitalize with consultation * Use prophylactic GTN (systemic dose?) * Monitor during work (pulse oximeter)

10 2. Myocardial Infarction (Heart Attack) Definition: - Necrosis of part of cardiac muscle due to acute attack of ischemia - Same pain with angina but more severe & not relieved by rest or GTN & may be associated with nausea, vomiting & dyspnea +/- syncope - MI is a hot medical emergency, 50% die in the 1 st hour and 20% in the next hours

11 - >50 % of MI is without previous angina Diagnosis: 1. Symptoms (up to 20% silent MI) 2. ECG changes 3. Elevated cardiac enzymes: Troponin I, CK, AST, LDH 4. Arrhythmias 5. Cardiogenic shock 6. Acute HF

12 Dental management if history of MI MI 6 months MI 6-12 months MI > 12 months Elective Dental Procedure Emergency Dental Procedure Elective Surgical Procedure Emergency Surgical Procedure Defer Only after Consultation Defer OK but: Defer - Consult physician, better hospitalize - Stress reduction - Prophylactic GTN - Ready medical help in case of ER - Minimize adrenaline LA - Monitoring with pulse oximeter - Check anticoagulant therapy Treat normally but: - Stress reduction - Short visit - If angina, treat as angina - Minimize adrenaline LA - Check anticoagulant therapy

13 II. Hypertension (HTN) Definition (WHO/ISH): - Elevated BP of 140/90 on two separate occasions - Optimal BP: < 120/80 - Pre-hypertension: 120/80 139/89 Causes: - > 90% is Primary (essential) HTN (idiopathic or unknown cause) - < 10% is Secondary HTN (Renal disease, Endocrine, Cerebral, Drugs)

14 Dental management of hypertensive patients Controlled (ASA Grade I) BP < 140/90 (ASA Grade II) BP < 160/100 Uncontrolled (BP 140/90) (ASA Grade III) BP 180/110 (ASA Grade IV) BP > 180/110 Treat as normal patient but take these measures: - Stress reduction - Short visits - Late morning visit - Aspirating syringe - Sedation is preferable if anxious patient - Minimize epinephrine- LA if on beta blockers - Avoid sudden raising patient from supine - Recheck BP after 5 min. - Take same measures (as grade I) - Recheck BP after 5 min. - Consult physician before - Minimize adrenaline LA - Take same measures - Recheck BP after 5 min. - Defer elective treatment - If dental emergency (excluding extraction): *Consult physician *Take same measures but adrenaline-la is contraindicated

15 Risks in hypertensive patients during dental work: - Acute hypertensive crisis that may cause: 1. Stroke (CVA) cerebral damage 2. Renal damage 3. Retinal damage - Cardiac complications - Bleeding

16 IV. Cardiac Arrhythmias Check associated diseases If cardiac pacemaker: - Minimize epinephrine-la amount - MRI, electro cautery, ultrasonic scalers, electronic dental analgesia are contraindicated - Other electrical units are safer but also avoid if possible or keep it away 30 cm. at least - Defer elective dental care if pacemaker is inserted few weeks ago

17 V. Valvular Disease 1. Rheumatic Fever - Acute febrile illness with poly arthralgia following sore throat caused by Beta- Haemolytic Streptococci - Affects children 5-15 y but very rare now - May lead to carditis with damage to the heart valves (rheumatic heart disease) due to cross immunity with ASO Antibody - Treated by oral penicillin until age of 20

18 Dental management of RHD patients Check anticoagulant therapy Consult physician before work Note. Rheumatic heart disease carries very minor risk of infective endocarditis

19 2. Infective Endocarditis (IE) Definition: - Infection of the endocardium mainly in a damaged valve following bacteremia - Very rare but life-threatening & difficult to treat (prevention is better than cure) - Bacteremia of oral cavity source that may cause IE is: Streptococcus Viridans (mutans & sanguis)

20 Risk factors (patients at risk of IE): - Prosthetic valve - Previous IE - Cyanotic congenital heart defect (CHD) - Mitral valve prolapse with regurgitation - Rheumatic heart disease (RHD) - Hypertrophic cardiomyopathy

21 Highest risk patients for IE 1. Prosthetic cardiac valve 2. Previous infective endocarditis 3. Congenital heart disease (CHD) if: - Unrepaired & Cyanotic - Completely repaired with prosthetic material or device during first six months - Repaired but residual defects 4. Valvular defect in a transplanted heart

22 Dental procedures that may cause IE: - Any procedure causes bacteremia: * Surgery (including extraction) * Periodontic procedures * Intraligamental LA * Apical over instrumentation

23 Management of patients at risk of IE Stress reduction Check anticoagulant therapy (esp. prosthetic valve) Emphasize on the oral prevention measures (oral hygiene, fluoride, fissure sealants etc.) Follow ONE of the following protocols regarding antibiotic prophylaxis for IE:

24 1. UK Protocol (NICE 2008): - Antibiotic prophylaxis for IE is NOT recommended in dental procedures Why? USA Protocol (ADA/AHA 2007): - AB prophylaxis is recommended for high risk patients ONLY (check slide 21)

25 AB Regimen for Prophylaxis against IE (ADA/AHA 2007) SITUATION AGENT Adults Children Oral Amoxicillin 2 g 50 mg/kg Unable to take oral Ampicillin OR Cefazolin or Ceftriaxone 2 g IV or IM 1 g IV or IM 50 mg/kg IV or IM Allergic to Penicillins Clindamycin OR Azithromycin OR Cephalexin** 600 mg PO 500 mg PO 2 g PO 20 mg/kg PO 15 mg/kg PO 50 mg/kg PO Allergic to Penicillins & unable to tale oral Clindamycin OR Cefazolin** or Ceftriaxone** 600 mg IV/IM 1 g IV/IM 20 mg/kg IV/IM 50 mg/kg IV/IM ** Contraindicated if severe allergy to Penicillin (esp. anaphylaxis)

26 * AB prophylaxis should be give 1 h before the procedure (for oral dose) and 30 min. before for injections (IV/IM) * If you forget to give AB before, you can give it up to 2 h * Avoid IM injections if patient on anticoagulant * If patient is already on oral AB, change the class of AB * If already on IV AB, just adjust the timing of procedure (no extra dose)

27 VI. Heart Failure Definition: - Cardiac output is not sufficient to meet the body need - Can be Lt-sided or Rt-sided or both - Most common cause of HF is: IHD - Other causes: HTN & Valve disease (Lt), COPD & PE (Rt), Hyperthyroidism, Anemia & Arrhythmias - Diagnosis by ECHO cardiography

28 Dental management of HF patients Controlled Uncontrolled (dyspnea at rest or minimal effort, nocturnal angina) Treat normally but: - Stress reduction - Late morning visit, short visit - Check drugs & underlying cause - Supine position is contraindicated - Consult physician - Delay elective treatment until controlled - Only non surgical emergency allowed, otherwise hospitalize

29 VII. Cardiac Transplant All transplant patients are immunocompromised. Why? Adrenaline-LA is best avoided Check Steroids & Anticoagulants If extraction/surgery: give prophylactic AB to prevent wound infection (NOT IE) First 6 months, defer elective treatment If emergency surgical treatment at first 6 months, consult physician for possible prophylaxis for IE

30 Thank You