Dental Management of Medical Compromised Patients

8/2/2019 Dental Management of Medical Compromised Patients

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Dental management of medical

compromised patients

Infective Endocarditis :

Infective endocarditis (IE) is a microbial infection of theendothelial surface of the heart or heart valvesthat most often occurs in proximity to congenital or acquiredcardiac defects. A clinically andpathologically similar infection that may occur in the endotheliallining of an artery, usually adjacent to avascular defect (e.g., coarctation of the aorta) or a prostheticdevice (e.g., arteriovenous [AV] shunt), iscalled infective endarteritis . Although bacteria most often causethese diseases, fungi and other

microorganisms may also cause infection; thus, the term infectiveendocarditis (IE) is used to reflect thismultimicrobial origin. The term bacterial endocarditis (BE)commonly is used, reflecting the fact that mostcases of IE are due to bacteria.

IE is a disease of significant morbidity and mortality that is difficultto treat; therefore, emphasis has longbeen directed toward prevention. Historically, various dental

procedures have been implicated as asignificant cause of IE because the oral flora is frequently found tobe the causative agent. Furthermore,whenever a patient is given a diagnosis of IE caused by oral flora,dental procedures performed at anypoint within the previous several months have typically beenblamed for the infection. As a result,antibiotics have been administered prior to certain invasive dentalprocedures in an attempt to preventinfection. It is of note, however, that the effectiveness of thispractice in humans has never been



substantiated, and that accumulating evidence questions the

validity of this practice.

SIGNS AND SYMPTOMS:

The classic findings of IE include fever, heart murmur, andpositive blood culture, although the clinicalpresentation may be varied. It is of particular significance that theinterval between the presumed initiatingbacteremia and the onset of symptoms of IE is estimated to beless than 2 weeks in more than 80% ofpatients with IE. In many cases of IE that have been purported tobe due to dentally inducedbacteremia, the interval between the dental appointment and thediagnosis of IE has been much longerthan 2 weeks (sometimes months), and thus it is very unlikely thatthe initiating bacteremia wasassociated with dental treatment.

Dental Procedure/Oral Manipulation Reported Frequency ofBacteremia:

Tooth extraction 10%-100%

Periodontal surgery 36%-88%

Scaling and root planing 8%-80%

Teeth cleaning ≤40%

Rubber dam matrix/wedge placement 9%-32%

Endodontic procedures ≤20%

Toothbrushing and flossing 20%-68%

Use of wooden toothpicks 20%-40%Use of water irrigation devices 7%-50%

Chewing food 7%-51%

Efficacy of Antibiotic Prophylaxis:

The assumption that antibiotics given to at-risk patients priorto a dental procedure will prevent or reducea bacteremia that can lead to IE is controversial. Some studiesreport that antibiotics administered prior to



a dental procedure reduced the frequency, nature, and/or durationof bacteremia, althoughothers did not. Recent studies suggest that amoxicillin therapy hasa statistically significant

impact on reducing the incidence, nature, and duration of bacteriaassociated with dental procedures, butit does not eliminate bacteremia. However, no data show thatsuch a reduction caused byantibiotic therapy reduces the risk of or prevents IE.

DENTAL MANAGEMENT

Antibiotic Prophylaxis:

Dental treatment has long been implicated as a significantcause of IE. Conventional wisdom has taughtthat in a patient with a predisposing cardiovascular disorder, IEwas most often due to a bacteremia thatresulted from an invasive dental procedure, and that through theadministration of antibiotics prior tothose procedures, IE could be prevented. Based on theseassumptions, over the past 50 years, the AHA

published nine sets of recommendations for antibiotic prophylaxisfor dental patients at risk for . These recommendations, first putforth in 1955 and revised every few years, varied in terms of identification of risk conditions, selectionof antibiotics, timing of antibioticadministration, and route of administration of antibiotics. It isimportant to recognize that although theserecommendations were a rational and prudent attempt to preventlife-threatening infection, they were

largely based on circumstantial evidence, expert opinion, clinicalexperience, and descriptive studies inwhich surrogate measures of risk were used. Furthermore, theeffectiveness of theserecommendations has never been proved inhumans. Recently, accumulating evidence suggests that

Prolonged Dental Appointment:

The length of a dental appointment in relation to the effective

plasma concentration of an administered



antibiotic is not addressed in these recommendations; however, fora lengthy appointment, this may be amatter of concern. With amoxicillin, which has a half-life ofapproximately 80 minutes, the average peak

plasma concentration of 4 μg/mL is reached about 2 hours afteroral administration of a 250-mg dose.

Most of the penicillin-sensitive viridans group streptococci have anMIC requirement of 0.2 μg/mL.

Thus, it would appear that a 2-g dose of amoxicillin would producean acceptable MIC for at least 6hours. If a procedure lasts longer than 6 hours, it may be prudent

to administer an additional 2-g dose.

Heart 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

Symptoms of Heart Failure:

Dyspnea (perceived shortness of breath)• Fatigue and weakness• Acute pulmonary edema (cough)• Exercise intolerance (inability to climb a flight of stairs)• Fatigue (especially muscular)• Dependent edema (swelling of feet and ankles after standing orwalking)• Report of weight gain or increased abdominal girth (fluidaccumulation; ascites)• Anorexia, nausea, vomiting, (bowel edema)• Hyperventilation followed by apnea during sleep• Heart murmur

Other manifestation related to drugs:

Lesions



Dry mouthascites

Dental management:

Obtain consultation

avoid use of vasoconstrictors if use is considered essential,discuss with physician.Use semisupine or upright chair position.( Patients with HF may

nottolerate a supine chair position because of pulmonary edema andwill need a semisupine or upright chairposition.)anesthesia is without adrenaline.

Ischemic Heart Disease:

Coronary atherosclerotic heart disease is a major healthproblem in the United States and in otherindustrialized nations. Atherosclerosis is the thickening of theintimal layer of the arterial wall caused bythe accumulation of lipid plaques. The atherosclerotic processresults in a narrowed arterial lumen with

diminished blood flow and oxygen supply. Atherosclerosis is themost common underlying cause of notonly coronary heart disease (angina and myocardial infarction [MI])but also cerebrovascular disease(stroke) and peripheral arterial disease (intermittent claudication).Symptomatic coronary atherosclerotic heart disease is oftenreferred to as ischemic heart disease.Ischemic symptoms are the result of oxygen deprivation caused byreduced blood flow to a portion of themyocardium. Other conditions such as embolism, coronary ostialstenosis, coronary artery spasm, and



congenital abnormalities also may cause ischemic heart disease.

CLINICAL PRESENTATION:

Symptoms:

Chest pain is the most important symptom of coronaryatherosclerotic heart disease. The pain may bebrief, as in angina pectoris resulting from temporary ischemia ofthe myocardium, or it may be prolonged,as in unstable angina or AMI. Ischemic myocardial pain resultsfrom an imbalance between the oxygen

supply and the oxygen demand of the muscle. Atheroscleroticnarrowing of the coronary arteries is animportant cause of this imbalance. The exact mechanism oragents involved in producing the cardiac pain

are not known.

DENTAL MANAGEMENT:

Medical ConsiderationsRisk assessment for the dental management of patients withischemic heart disease involves three

determinants:

1. Severity of the disease2. Type and magnitude of the dental procedure3. Stability and reserve of the patient

Dental Management Considerations for Patients WithUnstable Angina or Recent MyocardialInfarction [*]

• Avoid elective care• If treatment is necessary, consult with physician and limittreatment to pain relief, treatment ofacute infection, or control of bleeding• Consider including the following:•

Prophylactic nitroglycerin• Placement of intravenous line



• Sedation• Oxygen• Continuous electrocardiographic monitoring

• Pulse oximeter

• Frequent monitoring of blood pressure• Cautious use of epinephrine in local anesthetic, combined withabove measures

* Myocardial infarction within the past 30 days.

Dental Management Considerations for Patients With StableAngina or Past History ofMyocardial Infarction [*]• Morning appointments• Short appointments• Comfortable chair position• Pretreatment vital signs• Nitroglycerin readily available• Stress-reduction measures:• Good communication• Oral sedation (e.g., triazolam 0.125- to 0.25 mg on the nightbefore and 1 hour

before the appointment)• Intraoperative N2O/O2• Excellent local anesthesia• Limited use of vasoconstrictor (maximum 0.036 mg epinephrine,0.20 mg levonordefrine);also applicable if patient is taking a nonselective beta-blocker• Avoidance of epinephrine-impregnated retraction cord• Antibiotic prophylaxis not recommended for patients withcoronary artery stents•

Antibiotic prophylaxis not recommended for history of coronaryartery bypass graft (CABG)• Avoidance of anticholinergics (e.g., scopolamine, and atropine)• Adequate postoperative pain control* Defined as longer than 1 month since myocardial infarction (MI),with no ischemic symptoms. It is recommended that at least4 to 6 weeks should elapse after an uncomplicated MI beforeelective procedures are performed.

The use of vasoconstrictors in local anesthetics posespotential problems for patients with ischemic heart



disease because of the possibilities of precipitating cardiactachycardias, arrhythmias, and increases inblood pressure. Local anesthetics without vasoconstrictors may beused as needed. If a vasoconstrictor

is necessary, patients with intermediate risk and those takingnonselective beta blockers can safely begiven up to 0.036 mg epinephrine (2 cartridges containing1:100,000 epi) or 0.20 mg levonordefrin (2cartridges containing 1:20,000l evo); intravascular injections areavoided. Greater quantities ofvasoconstrictor may well be tolerated, but increasing quantitiesincrease the risk of adversecardiovascular effects. For patients at higher risk, the use of

vasoconstrictors should be discussed withthe physician. Studies have shown, however, that modestquantities of vasoconstrictors may be usedsafely even in high-risk patients when accompanied by oxygen,sedation, nitroglycerin, and excellent paincontrol measures.For patients at all levels of cardiac risk, the use of gingivalretraction cord impregnated with epinephrineshould be avoided because of the rapid absorption of a highconcentration of epinephrine and the

potential for adverse cardiovascular effects. As an alternative,plain cord saturated with tetrahydrozolineHCl 0.05% (Visine; Pfizer Inc, New York, NY) or oxymetazolineHCl 0.05% (Afrin; Schering-Plough,Summit, NJ) provides gingival effects equivalent to those ofepinephrine without adverse cardiovasculareffects.Patients who take daily aspirin (160 to 325 mg) can expect someincrease in surgical and postoperative

bleeding, but this is generally not clinically significant and can becontrolled with local measures only.Discontinuation of these agents before dental treatment generallyis unnecessary.

Arrhythmia:



An irregular heartbeat is an arrhythmia (also calleddysrhythmia). Heart rates can also be irregular. A normal heartrate is 50 to 100 beats per minute. Arrhythmias and abnormal

heart rates don't necessarily occur together. Arrhythmias can occurwith a normal heart rate, or with heart rates that are slow (calledbradyarrhythmias -- less than 50 beats per minute). Arrhythmiascan also occur with rapid heart rates (called tachyarrhythmias --faster than 100 beats per minute). In the United States, more than850,000 people are hospitalized for an arrhythmia each year.

Major Causes of Cardiac Arrhythmias:

• Primary cardiovascular disease• Pulmonary disorders• Autonomic disorders• Systemic diseases• Drug-related adverse effects

• Electrolyte imbalances

Signs and Symptoms of Cardiac Arrhythmias:

SIGNS:

• Slow heart rate (<60 beats/min)• Fast heart rate (>100 beats/min)• Irregular rhythm

SYMPTOMS:

•

Palpitations• Fatigue• Dizziness• Syncope• Angina• Congestive heart failure• Shortness of breath• Orthopnea

• Peripheral edema.

DENTAL MANAGEMENT:



Medical Considerations

Stress associated with dental treatment or excessive amounts ofinjected epinephrine may lead to lifethreatening

cardiac arrhythmias in susceptible dental patients. Patients with anexisting arrhythmia,diagnosed or undiagnosed, are at increased risk in the dentalenvironment. In addition, patients at risk fordeveloping an arrhythmia may be in danger in the dental office ifthey are not identified and measures arenot taken to minimize stressful situations that can precipitate anarrhythmia. Other patients may have

their arrhythmias under control with the use of drugs or a

pacemaker but require special consideration when receiving dental treatment. The keys to successful dentalmanagement of patients prone todeveloping a cardiac arrhythmia and those with an existingarrhythmia are identification and prevention.Even under the best of circumstances, however, a patient maydevelop a cardiac arrhythmia that requiresimmediate emergency measures.Identification of patients with a history of an arrhythmia, those with

an undiagnosed arrhythmia, and thoseprone to developing one is the first step in risk assessment and inavoiding an untoward event .This is accomplished by obtaining a thorough medical history,including a pertinent review of systems,and taking and evaluating vital signs (pulse rate and rhythm, bloodpressure, respiratory rate). In a reviewof systems, patients should be asked about the presence of signsor symptoms related to the

cardiovascular and pulmonary systems. Patients who reportpalpitations, dizziness, chest pain, shortnessof breath, or syncope may have a cardiac arrhythmia or othercardiovascular disease, and should beevaluated by a physician. Patients with an irregular cardiac rhythm(even without symptoms) also mayrequire consultation with the physician to determine itssignificance.

Patients with a known history of arrhythmia should be questionedas to the type of arrhythmia (if known),



how it is being treated, medications being taken, presence of apacemaker or defibrillator, effects on theiractivity, and stability of their disease. Because the classificationand diagnosis of arrhythmia are often

complex, patients often do not know the specific diagnosis that hasbeen assigned to their disorder; thus,the physician must be relied upon to provide this information. It isimportant to identify any known triggers,such as stress, anxiety, or medications. Patients with a history ofother heart, thyroid, or chronicpulmonary disease should be identified, as these may be a causeof or contributor to the arrhythmia, andthey may require special management as well. If any questions or

uncertainties arise, a medicalconsultation should be sought regarding patient diagnosis andcurrent status, and to aid the dentist inassessing risk for aggravating or precipitating a cardiacarrhythmia, stroke, or MI during or in relation todental treatment.The dentist must make a determination of the risk involved inproviding dental treatment to a patient witha history of arrhythmia and must decide whether the benefits oftreatment outweigh any risk. This often

requires consultation with the physician. have published guidelinesthat can help to make this determination. These guidelines areintended for use by physicians who are evaluating patients withcardiovascular disease to determinewhether they can safely undergo surgical procedures. They alsomay be applied to the provision of dental

care and may be of significant value to the dentist in making a

determination of risk.

Perioperative Risk and Dental Treatment for Patients WithCardiac Arrhythmias:

ARRHYTHMIAS ASSOCIATED WITH MAJOR PERIOPERATIVE

RISK

• High-grade atrioventricular (AV) block• Symptomatic ventricular arrhythmias in the presence of

underlying heart disease• Supraventricular arrhythmias with uncontrolled ventricular rate



Dental Management: Avoid elective dental care.

ARRHYTHMIAS ASSOCIATED WITH INTERMEDIATE

PERIOPERATIVE RISK

• Pathological Q waves on electrocardiogram (ECG) (markers ofprevious myocardialinfarction) Dental Management: Elective dental care OK.

ARRHYTHMIAS ASSOCIATED WITH MINOR PERIOPERATIVERISK

• ECG abnormalities consistent with:• Left ventricular hypertrophy• Left bundle-branch block• ST-T abnormalities• Any rhythm other than sinus (e.g., atrial fibrillation)

Dental Management Recommendations for PatientsWith Cardiac Arrhythmias

STRESS AND ANXIETY REDUCTION

• Establish good rapport• Schedule short, morning appointments

• Ensure comfortable chair position

• Provide preoperative sedation (short-acting benzodiazepine nightbefore and/or 1 hour before appointment)

• Administer intraoperative sedation (nitrous oxide/oxygen)• Obtain pretreatment vital signs• Ensure profound local anesthesia

• Provide adequate postoperative analgesia

VASOCONSTRICTORS:

• Epinephrine-containing local anesthetic can be used with

minimal risk if the dose is limited to



0.036 mg epinephrine (2 capsules containing 1:100,000concentration). Higher doses may be

tolerated, but the risk of complications increases with dose. Avoid

the use of epinephrine in retraction cord.

FOR PATIENTS WITH ATRIAL FIBRILLATION WHO ARE

TAKING WARFARIN (COUMADIN):

• Should have current international normalized ratio (INR)(within 24 hours of surgicalprocedure)• If INR is within the therapeutic range (INR, 2.0-3.5), dentaltreatment, including minor oral

surgery, can be performed without stopping or altering theCoumadin• Local measures include gelatin sponge or oxidized cellulose insockets, suturing, gauze

pressure packs, preoperative stents, and tranexamic acid or ε-

aminocaproic acid mouth rinse

and/or to soak gauze

FOR PATIENTS WITH PACEMAKERS:

• Antibiotic prophylaxis to prevent bacterial endocarditis is notrecommended

• Avoid the use of electrosurgery and ultrasonic scalers

FOR PATIENTS TAKING DIGOXIN:

•

Watch for signs or symptoms of toxicity (e.g., hypersalivation)• Avoid epinephrine or levonordefrine

FOR THE HIGH-RISK PATIENT WHO REQUIRES URGENTCARE, CONSIDER TREATING IN

SPECIAL CARE CLINIC OR HOSPITAL:

• Consult with physician• Provide limited care only for pain control, treatment of acute

infection, or control of bleeding• Intravenous line



• Sedation• Electrocardiogram (ECG) monitoring• Pulse oximeter• Blood pressure monitoring

•Avoid or limit epinephrine

Hypertension:

Hypertension is an abnormal elevation in arterial pressurethat can be fatal if sustained and untreated.People with hypertension may not display symptoms for many

years but eventually can experiencesymptomatic damage to several target organs, including kidneys,heart, brain, and eyes. In adults, asustained systolic blood pressure of 140 mm Hg or greater and/ora sustained diastolic blood pressure of

90 mm Hg or greater is defined as hypertension.

The dental health professional can play a significant role in thedetection and control of hypertension andmay well be the first to detect a patient with an elevation in bloodpressure or with symptoms ofhypertensive disease. Along with detection, monitoring is anequally valuable service because patientswho are receiving treatment for hypertension but may not beadequately controlled because of poor

compliance or inappropriate drug selection or dosing.

The dental patient with hypertension poses several potentiallysignificant management considerations.

These include identification of disease, monitoring, stress andanxiety reduction, prevention of drug

interactions, and awareness and management of drug adverse

effects.

Identifiable Causes of Hypertension:

• Chronic kidney disease•

Coarctation of the aorta



• Cushing's syndrome and other glucocorticoid excess states,including chronic long-termsteroid therapy• Drug-induced or drug-related (e.g., NSAIDs, oral contraceptives,

decongestants)• Obstructive uropathy• Pheochromocytoma• Primary aldosteronism and other mineralocorticoid excess states• Renovascular hypertension• Sleep apnea

• Thyroid or parathyroid disease

NSAIDs, Nonsteroidal anti-inflammatory drugs.

Signs and Symptoms of Hypertensive Disease:

EARLY

• Elevated blood pressure readings• Narrowing and sclerosis of retinal arterioles• Headache• Dizziness•

Tinnitus

ADVANCED

• Rupture and hemorrhage of retinal arterioles• Papilledema• Left ventricular hypertrophy• Proteinuria• Congestive heart failure• Angina pectoris• Renal failure• Dementia• Encephalopathy

Dental Management Recommendations for PatientsWith Hypertension:

• Stress/anxiety reduction• Establishment of good rapport



• Short, morning appointments• Consider premedication with sedative/anxiolytic• Consider intraoperative use of nitrous oxide/oxygen• Obtain excellent local anesthesia; OK to use epinephrine in

modest amounts• Cautious use of epinephrine in local anesthetic in patients takingnon-selective b-betablockers or peripheral adrenergic antagonists• Avoid the use of epinephrine-impregnated gingival retraction cord• Consider periodic intraoperative BP monitoring for patients withupper level stage 2hypertension; terminate appointment if BP rises above 179/109• Slow position changes to prevent orthostatic hypotension

BP, Blood pressure.

Dental Management of Medical Compromised Patients

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