Dental Management Of Medically Compromised Patients

1. Dental Management Of Medically Compromised Patients

2. * Medically compromised patients are those patients for dental treatment patients “ at risk “ on dent chair .* An alert dentist should take all the precautions needs before any dental procedures OR dental surgery starts.* Systemic diseases / disorders may increase the risk accompanied with a great complications that might be threatening patient life .

3. SYSTEMIC DISORDERDS THAT DENTISTS SHOULD BE AWARE OF :1) Bleeding disorders Including anti coagulant medications2) cardiac disease /cardiac defects3) cardiovascular problems as high blood pressure and arrhythmia 4) Diabetes5) Infectious diseases as T.B ,HIV and hepatitis also herpes and flu

4. 6) Immuno- suppressive and Autoimmune diseases7) Pregnancy 8) kidney disorders / andtransplantation9) Liver Disease10) central nervous system like seizured brain strokes

5. I) management of Bleeding disorders including patients on anticoagulants :Diagnostic tests ::1) bleeding problems secondary to liver Diseases * prothrombin time(pt) * partial thrombin time (ptt) * international normalized ratio (inr) 2) asprin and other anti inflammatory agents * bleeding time (BT) 3) thrombocytopenia * cbc with differential blood count * bleeding time (bt) 4) anticoagulant warfarin * pt * INR

6. Chair side management and precautions during dental treatment 1) NO treatment should be started : * IF bleeding time is greater than 10 minutes * IF platelets count is less than (60,000 ) * IF ( PTT) is greater than 45 seconds * IF (PT) is greater than 22 seconds * IF (INR) is greater than 3.5

7. 2) If bleeding records are seen greater than above. * medical consultation is needed to , * decrease the anticoagulant doses * Vit. K administration 3) Apply primary closure and/or apply pressure over the bleeding site . 4) Gel Foam may help to close the surgical site 5) Avoid unnecessary and meticulous procedures 6) Antibiotic administration to avoid super imposed infection and /also to promote healings

8. ii) management of Cardiac and cardiovascular defects : * Medical Consultations ( high priority ) to get clearance for Dent. treatment * Prophylactic antibiotics cover, to avoid cases of bacterial endocarditis ( before , during , after) according to Med. Consultations . * Patients unable to take oral administration may go for I.V/I.M administration ( 2.0 gr. = 4 /500 mg) for adults (50mg/kg) for kids one hour before any procedures starts. * If patient is allergic to penicillin , cephalosporin's can help , except in cases of hypersensitivity reactions i.eurticaria ,angiodema and anaphylaxis

9. III) Diabetes periodontal surgical corrections for the consideration of : * High risk. * Delayed healing. * Post surgical complicationsCases of uncontrolled diabetes constitute a real problem to dentist on chair side treatment for those patients ( BEFORE), asking the patient to show and prove that his/her blood sugar level is within the normal readings required, to start any invasive treatment i.e surgical extraction , or prolonged procedures .

10. Diagnostic tests needed and precautions : 1) Strong medical and dental history 2) Medical consultation should preceedsthe following precautions 3) Fasting bld. Sugar level test ( less than 120mg/dl) 4) Random plasma glucose( less than 200mg/dl) 5) Patients should have taken their medications before procedures 6) Antibiotic cover (if needed)

11. V) Infectious Diseases(T.B,HIV,Hepatitis,Herpes and Flu) Diagnostic Tests: A)Tubeculosis (T.B): * If tuberculin test is positive ,then chest x-rays is needed …… and * If chest x-ray is positive or there is obvious active infection , then * Two active sputum test for tuberculosis baccilli ( acid fast bacillus test) should be carried out to confirm the disease

12. B) Hepatitis :• It is DNA virus lives and multiplies in hepatic cells. • The virus is identified in the serum as 3 types of antigen. 1. Surface antigen (s)HBsAg Seen in serum 6 weeks after incubation period. 2. Core antigen (c) HBcAg Present in liver cells, not detected in the serum 3. Envelope antigen (e) HBeAg - It indicate high infectivity - It appears in acute condition.. TESTS : 1- Clinical features and PCR and ELISA test 2-Elevated liver enzymes: SGPT, SGOT. 3-Elevated Prothrombin Time, ESR. 4- Serologic tests: Antigens& antibodies

13. C) HIV Tests : • *Virus can be easily isolated from either blood and semen , yet …… • * current laboratory tests including T-cell count. • * Viral isolation • * CBC Differential blood count for RBC’s ,WBC’s • platelets count • D) herpes / flu : • * No specific laboratory test needed • * virus isolation ( swab biopsy )

14. Management of patients with infectious diseases 1) Under all circumstances Medical consultation / and clearance should be obtained before any treatment starts , and / also no elective treatment should be carried out before physician says patient is no longer infectious 2) All precautions should be under taken if necessary treatment should be carried out 3) In cases of HIV , Hepatitis , T.B and herpes , the normal universal precautions 4) Patients should be reappointed in cases of acute exacerbation and remission OR the patient are too weak to stands the dental procedures OR when the patient should get back to his medications before any dental chair side treatment starts .

15. VI) Management of patients with Immunosuppressive & autoimmune Diseases *Autoimmune , immunosuppressive and / also patient on immunosuppressive medications should have a restricted chair Side dental treatment to avoid risk factor specially in cases of HIV , leukemia , primary immunosuppressive diseases also cancer chemotherapeutic agents for patient having organ transplantation i.e liver / kidney and /or patients on corticosteroid hormones as a treatment for autoimmune disorders . Precautions : *Medical consultation * Aggressive and invasive dental procedures should be avoided * Proper /clean oral hygiene * Antibiotic cover if needed * Prophylaxis for viral and fungal infection is considered * Low readings of differential blood count as concern WBC’s ,RBC’s and platelets count patient reappointment

16. VII) Pregnancy **Management of pregnant women on dental chair: 1) First three months * NO dental treatment , NO dental x-rays , NO invasive or aggressive procedures * Emergencies ONLY , after * Medical consultation to determine the suitable medication needed for the patient and /also a clearance is needed to confirm treatment start !! 2) Second and first half of third trimester : * These are the appropriate and safest time for all desired dental treatment needed during pregnancy along with minimum drug use + clearance 3) Last half of third trimester : * NO dental treatment Except emergencies along with med. clearance and minimum drugs / trauma

17. VII) Dental Management of patients with liver disorders & patient on anticoagulant medications Tests needed : Liver function tests Prothrombin time (PT) Partial thromboplstin time (PTT) INR (international normalized ratio) Bleeding time (BT) SGOT , AST , and ATL

18. Precautions : 1) Medical clearance/consultation 2) Before all readings are back to normal NO dental treatment should be started as concern liver function tests , and bleeding time 3) Avoidance of drugs that are toxic to the liver metabolization 4) Maintain high oral hygiene 5) Minimum surgical procedures

19. IX) Dental Management ofpatients with kidney disorders Diagnostic tests : * BUN ( blood , urea , and nitrogen ) * Creatine clearance rate . Precautions : 1) Avoid drug toxicity / accumulation 2) Avoid invasive procedures to avoid poor and delayed healing 3) Avoid long chair side treatment for pt’s with kidney transplant /complications 4) Medical consultation / clearance 5) Prophylactic Antibiotic cover