85896594 dental management of medical compromised patients

7/21/2019 85896594 Dental Management of Medical Compromised Patients

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hg

Dental management of

medical compromised

patients

Infective Endocarditis :

Infective endocarditis (IE) is a microbial infection ofthe endothelial surface of the heart or heart valvesthat most often occurs in proximity to congenital oracquired cardiac defects. A clinically andpathologically similar infection that may occur in theendothelial lining of an artery, usually adjacent to avascular defect (e.g., coarctation of the aorta) or aprosthetic device (e.g., arteriovenous A!" shunt), is

called infective endarteritis . Although bacteria most oftencause these diseases, fungi and othermicroorganisms may also cause infection# thus, the terminfective endocarditis (IE) is used to re$ect thismultimicrobial origin. %he term bacterial endocarditis (&E)commonly is used, re$ecting the fact that mostcases of IE are due to bacteria.

IE is a disease of signi'cant morbidity and mortality that is

dicult to treat# therefore, emphasis has longbeen directed toard prevention. *istorically, variousdental procedures have been implicated as asigni'cant cause of IE because the oral $ora is frequentlyfound to be the causative agent. +urthermore,henever a patient is given a diagnosis of IE caused byoral $ora, dental procedures performed at anypoint ithin the previous several months have typicallybeen blamed for the infection. As a result,antibiotics have been administered prior to certaininvasive dental procedures in an attempt to prevent


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infection. It is of note, hoever, that the eectiveness ofthis practice in humans has never beensubstantiated, and that accumulating evidence questions

the validity of this practice.

SIGNS AND SYMPTOMS:

%he classic 'ndings of IE include fever, heartmurmur, and positive blood culture, although the clinicalpresentation may be varied. It is of particular signi'cancethat the interval beteen the presumed initiatingbacteremia and the onset of symptoms of IE is estimated

to be less than - ees in more than /01 ofpatients ith IE.In many cases of IE that have beenpurported to be due to dentally inducedbacteremia, the interval beteen the dental appointmentand the diagnosis of IE has been much longerthan - ees (sometimes months), and thus it is veryunliely that the initiating bacteremia asassociated ith dental treatment.

Dental Procedure/Oral Manipulation Reported re!uenc" of#actere$ia:

Tooth extraction

10%-100%

Periodontal surgery

36%-88%

Scaling and root planing

8%-80%Teeth cleaning

0%

!u""er dam matrix#$edge placement

%-3&%

'ndodontic procedures

&0%

Tooth"rushing and (ossing

&0%-68%

)se of $ooden toothpic*s


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&0%-0%

)se of $ater irrigation de+ices

,%-0%

.he$ing food

,%-1%

'/cacy of nti"iotic Prophylaxis

%he assumption that antibiotics given to at2rispatients prior to a dental procedure ill prevent or reducea bacteremia that can lead to IE is controversial. 3omestudies report that antibiotics administered prior to

a dental procedure reduced the frequency, nature, and4orduration of bacteremia, althoughothers did not.5ecent studies suggest that amoxicillintherapy has a statistically signi'cantimpact on reducing the incidence, nature, and duration ofbacteria associated ith dental procedures, butit does not eliminate bacteremia. *oever, no data shothat such a reduction caused byantibiotic therapy reduces the ris of or prevents IE.

DENTA% MANAGEMENT

Antibiotic 6rophylaxis7

8ental treatment has long been implicated as asigni'cant cause of IE. 9onventional isdom has taughtthat in a patient ith a predisposing cardiovasculardisorder, IE as most often due to a bacteremia thatresulted from an invasive dental procedure, and thatthrough the administration of antibiotics prior tothose procedures, IE could be prevented. &ased on theseassumptions, over the past :0 years, the A*Apublished nine sets of recommendations for antibioticprophylaxis for dental patients at ris for . %heserecommendations, 'rst put forth in ;


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administration, and route of administration of antibiotics.It is important to recogni=e that although theserecommendations ere a rational and prudent attempt toprevent life2threatening infection, they ere

largely based on circumstantial evidence, expert opinion,clinical experience, and descriptive studies inhich surrogate measures of ris ere used.+urthermore,the eectiveness of theserecommendations has neverbeen proved in humans. 5ecently, accumulating evidencesuggests that

Prolon&ed Dental Appoint$ent:

%he length of a dental appointment in relation to theeective plasma concentration of an administeredantibiotic is not addressed in these recommendations#hoever, for a lengthy appointment, this may be amatter of concern. >ith amoxicillin, hich has a half2life ofapproximately /0 minutes, the average peaplasma concentration of ? @g4m is reached about - hoursafter oral administration of a -:02mg dose.

Bost of the penicillin2sensitive viridans group streptococcihave an BI9 requirement of 0.- @g4m.

%hus, it ould appear that a -2g dose of amoxicillin ouldproduce an acceptable BI9 for at least Chours. If a procedure lasts longer than C hours, it may be

prudent to administer an additional -2g dose.

'eart failure:a complex clinical syndrome that may result from any

structural or functional cardiac disorder that impairs the ability of

the ventricle to fill with or eject blood

S"$pto$s of 'eart ailure:


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Dyspnea (perceived shortness of breath)( Fatigue and weakness(Acute pulmonary edema (cough)( xercise intolerance (inability to climb a flight of stairs)

( Fatigue (especially muscular)( Dependent edema (swelling of feet and ankles after standing orwalking)( !eport of weight gain or increased abdominal girth (fluidaccumulation" ascites)(Anorexia# nausea# vomiting# (bowel edema)( $yperventilation followed by apnea during sleep( $eart murmur

%ther manifestation related to drugs:

&esionsDry mouth

ascites

Dental $ana&e$ent:

%btain consultationavoid use of vasoconstrictors if use is considered essential#discuss with physician'se semisupine or upright chair position'( atients with $F maynottolerate a supine chair position because of pulmonary edema andwill need a semisupine or upright chairposition')anesthesia is without adrenaline'

Isc)e$ic 'eart Disease:

9oronary atherosclerotic heart disease is a majorhealth problem in the Dnited 3tates and in other


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industriali=ed nations. Atherosclerosis is the thicening ofthe intimal layer of the arterial all caused bythe accumulation of lipid plaques. %he atheroscleroticprocess results in a narroed arterial lumen ith

diminished blood $o and oxygen supply. Atherosclerosisis the most common underlying cause of notonly coronary heart disease (angina and myocardialinfarction BI") but also cerebrovascular disease(stroe) and peripheral arterial disease (intermittentclaudication).3ymptomatic coronary atherosclerotic heart disease isoften referred to as ischemic heart disease.Ischemic symptoms are the result of oxygen deprivation

caused by reduced blood $o to a portion of themyocardium. ther conditions such as embolism, coronaryostial stenosis, coronary artery spasm, and

congenital abnormalities also may cause ischemic heart

disease.

*%INI*A% PRESENTATION:

3ymptoms7

9hest pain is the most important symptom of coronaryatherosclerotic heart disease. %he pain may bebrief, as in angina pectoris resulting from temporaryischemia of the myocardium, or it may be prolonged,as in unstable angina or ABI. Ischemic myocardial painresults from an imbalance beteen the oxygensupply and the oxygen demand of the muscle.

Atherosclerotic narroing of the coronary arteries is animportant cause of this imbalance. %he exact mechanismor agents involved in producing the cardiac pain

are not non.

DENTA% MANAGEMENT:

Bedical 9onsiderations

5is assessment for the dental management of patientsith ischemic heart disease involves three


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determinants7

+, 3everity of the disease-,%ype and magnitude of the dental procedure., 3tability and reserve of the patient

Dental Mana&e$ent *onsiderations for Patients it)0nsta1le An&ina or Recent M"ocardialInfarction 234

( Avoid elective care( If treatment is necessary, consult ith physician and limittreatment to pain relief, treatment of

acute infection, or control of bleeding( 9onsider including the folloing7( 6rophylactic nitroglycerin( 6lacement of intravenous line( 3edation( xygen( 9ontinuous electrocardiographic monitoring

( 6ulse oximeter

( +requent monitoring of blood pressure

( 9autious use of epinephrine in local anesthetic,combined ith above measures

F Byocardial infarction ithin the past G0 days.

Dental Mana&e$ent *onsiderations for Patients it) Sta1leAn&ina or Past 'istor" ofM"ocardial Infarction 234( Borning appointments

( 3hort appointments( 9omfortable chair position( 6retreatment vital signs( Hitroglycerin readily available( 3tress2reduction measures7( ood communication( ral sedation (e.g., tria=olam 0.;-:2 to 0.-: mg on thenight before and ; hourbefore the appointment)

( Intraoperative H-4-( Excellent local anesthesia


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( imited use of vasoconstrictor (maximum 0.0GC mgepinephrine, 0.-0 mg levonordefrine)#also applicable if patient is taing a nonselective beta2blocer

( Avoidance of epinephrine2impregnated retraction cord( Antibiotic prophylaxis not recommended for patients ithcoronary artery stents( Antibiotic prophylaxis not recommended for history ofcoronary artery bypass graft (9A&)( Avoidance of anticholinergics (e.g., scopolamine, andatropine)( Adequate postoperative pain controlF 8e'ned as longer than ; month since myocardial

infarction (BI), ith no ischemic symptoms. It isrecommended that at least? to C ees should elapse after an uncomplicated BIbefore elective procedures are performed.

%he use of vasoconstrictors in local anesthetics posespotential problems for patients ith ischemic heartdisease because of the possibilities of precipitating cardiactachycardias, arrhythmias, and increases in

blood pressure. ocal anesthetics ithout vasoconstrictorsmay be used as needed. If a vasoconstrictoris necessary, patients ith intermediate ris and thosetaing nonselective beta blocers can safely begiven up to 0.0GC mg epinephrine (- cartridges containing;7;00,000 epi) or 0.-0 mg levonordefrin (-cartridges containing ;7-0,000l evo)# intravascularinjections are avoided. reater quantities ofvasoconstrictor may ell be tolerated, but increasingquantities increase the ris of adversecardiovascular eects. +or patients at higher ris, the useof vasoconstrictors should be discussed iththe physician. 3tudies have shon, hoever, that modestquantities of vasoconstrictors may be usedsafely even in high2ris patients hen accompanied byoxygen, sedation, nitroglycerin, and excellent paincontrol measures.+or patients at all levels of cardiac ris, the use of gingivalretraction cord impregnated ith epinephrine


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should be avoided because of the rapid absorption of ahigh concentration of epinephrine and thepotential for adverse cardiovascular eects. As analternative, plain cord saturated ith tetrahydro=oline

*9l 0.0:1 (!isine# 6'=er Inc, He Jor, HJ) oroxymeta=oline *9l 0.0:1 (Afrin# 3chering26lough,3ummit, HK) provides gingival eects equivalent to thoseof epinephrine ithout adverse cardiovasculareects.6atients ho tae daily aspirin (;C0 to G-: mg) can expectsome increase in surgical and postoperativebleeding, but this is generally not clinically signi'cant andcan be controlled ith local measures only.

8iscontinuation of these agents before dental treatmentgenerally is unnecessary.

Arr)"t)$ia:

An irregular heartbeat is an arrhythmia (also calleddysrhythmia)' $eart rates can also be irregular' A normal heart rateis *+ to ,++ beats per minute' Arrhythmias and abnormal heartrates don-t necessarily occur together' Arrhythmias can occur witha normal heart rate# or with heart rates that are slow (calledbradyarrhythmias .. less than *+ beats per minute)' Arrhythmiascan also occur with rapid heart rates (called tachyarrhythmias ..faster than ,++ beats per minute)' /n the nited 0tates# more than1*+#+++ people are hospitali2ed for an arrhythmia each year'

Ma5or *auses of *ardiac Arr)"t)$ias:

( 6rimary cardiovascular disease( 6ulmonary disorders( Autonomic disorders( 3ystemic diseases( 8rug2related adverse eects

( Electrolyte imbalances


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Si&ns and S"$pto$s of *ardiac Arr)"t)$ias:

SIGNS:

( 3lo heart rate (LC0 beats4min)( +ast heart rate (M;00 beats4min)( Irregular rhythm

SYMPTOMS:

( 6alpitations( +atigue( 8i==iness

( 3yncope( Angina( 9ongestive heart failure( 3hortness of breath( rthopnea

( 6eripheral edema,

DENTA% MANAGEMENT:

Bedical 9onsiderations3tress associated ith dental treatment or excessiveamounts of injected epinephrine may lead tolifethreateningcardiac arrhythmias in susceptible dental patients.6atients ith an existing arrhythmia,diagnosed or undiagnosed, are at increased ris in thedental environment. In addition, patients at ris fordeveloping an arrhythmia may be in danger in the dental

oce if they are not identi'ed and measures arenot taen to minimi=e stressful situations that canprecipitate an arrhythmia. ther patients may have

their arrhythmias under control ith the use of drugs or a

pacemaer but require special consideration

hen receiving dental treatment. %he eys to successfuldental management of patients prone todeveloping a cardiac arrhythmia and those ith an

existing arrhythmia are identi'cation and prevention.


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Even under the best of circumstances, hoever, a patientmay develop a cardiac arrhythmia that requiresimmediate emergency measures.Identi'cation of patients ith a history of an arrhythmia,

those ith an undiagnosed arrhythmia, and thoseprone to developing one is the 'rst step in ris assessmentand in avoiding an untoard event .

%his is accomplished by obtaining a thorough medicalhistory, including a pertinent revie of systems,and taing and evaluating vital signs (pulse rate andrhythm, blood pressure, respiratory rate). In a revieof systems, patients should be ased about the presenceof signs or symptoms related to the

cardiovascular and pulmonary systems. 6atients horeport palpitations, di==iness, chest pain, shortnessof breath, or syncope may have a cardiac arrhythmia orother cardiovascular disease, and should beevaluated by a physician. 6atients ith an irregularcardiac rhythm (even ithout symptoms) also mayrequire consultation ith the physician to determine itssigni'cance.

6atients ith a non history of arrhythmia should bequestioned as to the type of arrhythmia (if non),ho it is being treated, medications being taen, presenceof a pacemaer or de'brillator, eects on theiractivity, and stability of their disease. &ecause theclassi'cation and diagnosis of arrhythmia are oftencomplex, patients often do not no the speci'c diagnosisthat has been assigned to their disorder# thus,the physician must be relied upon to provide thisinformation. It is important to identify any non triggers,such as stress, anxiety, or medications. 6atients ith ahistory of other heart, thyroid, or chronicpulmonary disease should be identi'ed, as these may bea cause of or contributor to the arrhythmia, andthey may require special management as ell. If anyquestions or uncertainties arise, a medicalconsultation should be sought regarding patient diagnosisand current status, and to aid the dentist inassessing ris for aggravating or precipitating a cardiacarrhythmia, stroe, or BI during or in relation to


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dental treatment.%he dentist must mae a determination of the risinvolved in providing dental treatment to a patient itha history of arrhythmia and must decide hether the

bene'ts of treatment outeigh any ris. %his oftenrequires consultation ith the physician.have publishedguidelines that can help to mae this determination. %heseguidelines areintended for use by physicians ho are evaluating patientsith cardiovascular disease to determinehether they can safely undergo surgical procedures.

%hey also may be applied to the provision of dental

care and may be of signi'cant value to the dentist in

maing a determination of ris.

Perioperative Ris6 and Dental Treat$ent for Patients it)*ardiac Arr)"t)$ias:

ARR'YT'MIAS ASSO*IATED IT' MA7OR PERIOPERATI8E

RIS9

( *igh2grade atrioventricular (A!) bloc( 3ymptomatic ventricular arrhythmias in the presence ofunderlying heart disease( 3upraventricular arrhythmias ith uncontrolledventricular rate

8ental Banagement7 Avoid elective dental care.

ARR'YT'MIAS ASSO*IATED IT' INTERMEDIATE

PERIOPERATI8E RIS9

( 6athological N aves on electrocardiogram (E9)(marers of previous myocardialinfarction) 8ental Banagement7 Elective dental care O.

ARR'YT'MIAS ASSO*IATED IT' MINOR PERIOPERATI8ERIS9

( E9 abnormalities consistent ith7


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( eft ventricular hypertrophy( eft bundle2branch bloc( 3%2% abnormalities( Any rhythm other than sinus (e.g., atrial 'brillation)

Dental Mana&e$ent Reco$$endations for Patientsit) *ardiac Arr)"t)$ias

STRESS AND ANIETY RED0*TION

( Establish good rapport( 3chedule short, morning appointments

( Ensure comfortable chair position( 6rovide preoperative sedation (short2actingben=odia=epine night before and4or ; hour beforeappointment)

( Administer intraoperative sedation (nitrous oxide4oxygen)( btain pretreatment vital signs( Ensure profound local anesthesia

( 6rovide adequate postoperative analgesia

8ASO*ONSTRI*TORS:

( Epinephrine2containing local anesthetic can be usedith minimal ris if the dose is limited to0.0GC mg epinephrine (- capsules containing ;7;00,000concentration). *igher doses may be

tolerated, but the ris of complications increases ith

dose. Avoid the use of epinephrine in retraction cord.

OR PATIENTS IT' ATRIA% I#RI%%ATION 'O ARE

TA9ING ARARIN ;*O0MADIN


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surgery, can be performed ithout stopping or altering the9oumadin( ocal measures include gelatin sponge or oxidi=edcellulose in socets, suturing, gau=e

pressure pacs, preoperative stents, and tranexamic acidor P2aminocaproic acid mouth rinse

and4or to soa gau=e

OR PATIENTS IT' PA*EMA9ERS:

( Antibiotic prophylaxis to prevent bacterialendocarditis is not recommended

( Avoid the use of electrosurgery and ultrasonic scalers

OR PATIENTS TA9ING DIGOIN:

( >atch for signs or symptoms of toxicity (e.g.,hypersalivation)

( Avoid epinephrine or levonordefrine

OR T'E 'IG'=RIS9 PATIENT 'O RE>0IRES 0RGENT*ARE? *ONSIDER TREATING IN

SPE*IA% *ARE *%INI* OR 'OSPITA%:

( 9onsult ith physician( 6rovide limited care only for pain control, treatment ofacute infection, or control of bleeding( Intravenous line( 3edation

( Electrocardiogram (E9) monitoring( 6ulse oximeter( &lood pressure monitoring

( Avoid or limit epinephrine

'"pertension:


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*ypertension is an abnormal elevation in arterialpressure that can be fatal if sustained and untreated.6eople ith hypertension may not display symptoms formany years but eventually can experience

symptomatic damage to several target organs, includingidneys, heart, brain, and eyes. In adults, asustained systolic blood pressure of ;?0 mm *g or greaterand4or a sustained diastolic blood pressure of


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(%hyroid or parathyroid disease

H3AI8s, Honsteroidal anti2in$ammatory drugs.

Si&ns and S"$pto$s of '"pertensive Disease:

EAR%Y

( Elevated blood pressure readings( Harroing and sclerosis of retinal arterioles( *eadache( 8i==iness(%innitus

AD8AN*ED

( 5upture and hemorrhage of retinal arterioles( 6apilledema( eft ventricular hypertrophy( 6roteinuria( 9ongestive heart failure( Angina pectoris

( 5enal failure( 8ementia(Encephalopathy

Dental Mana&e$ent Reco$$endations for Patientsit) '"pertension:

( 3tress4anxiety reduction( Establishment of good rapport( 3hort, morning appointments( 9onsider premedication ith sedative4anxiolytic( 9onsider intraoperative use of nitrous oxide4oxygen( btain excellent local anesthesia# O to use epinephrinein modest amounts( 9autious use of epinephrine in local anesthetic inpatients taing non2selective b2betablocers or peripheral adrenergic antagonists


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( Avoid the use of epinephrine2impregnated gingivalretraction cord( 9onsider periodic intraoperative &6 monitoring forpatients ith upper level stage -

hypertension# terminate appointment if &6 rises above;R

85896594 dental management of medical compromised patients

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