14. Preparation of patients with concomitant diseases / diabetes, hypertension, patients on anticoagulant therapy, etc Flashcards
🔸Inability of myocardium to pump enough blood
🔸Lungs/and or circulatory system become congested
Congestive heart failure
Stress in congestive heart failure should be avoided due to
🔸Increase workload of heart surpassing functional ability
🔸Pulmonary Oedema
Congestive heart failure symptoms
🔸Extreme dyspnoea
🔸Hyperventilation
🔸Cough
🔸Hemoptysis(pinkish foam expectoration)
🔸Difficulty breathing
Preferred patient position in congestive heart failure
Sitting position
Management of congestive heart failure
🔸Consultation with cardiologist
🔸 Oral premedication, e.g., 5–10 mg diazepam (Valium) or 1.5–3 mg bromazepam (Lexotanil), 1 h be-
fore procedure
🔸Small amount of vasoconstrictor
🔸Short appointments as painless as possible
Temporary ischemia in Myocardium, resulting in diminished oxygen
Angina Pectoris
Symptoms of angina
🔸 Brief paroxysmal pain posterior to the sternum
🔸 Burning sensation, pressure, or tightness
🔸 Pain radiating to the left shoulder, neck, left arm (with a numb sensation as well as tingling), sometimes down the chin and teeth of the mandible (usually the left side)
🔸Pain sometimes felt in epigastrium, causing confusion in diagnosis
🔸Perspiration
🔸Extreme anxiety
These patients have an increased risk of angina pectoris symptoms in dental surgery
Coronary heart disease history
Episode of angina pectoris precipitated by
🔸Fatugue
🔸Stress
🔸Rich meal
Symptoms of Angina Pectoris subside after
🔸2-5 minutes of rest
🔸Administering of vasodilator
Treatment of Angina pectoris
🔸Consultation with cardiologist
🔸 5–10 mg diazepam (Valium) or 1.5–3 mg bromazepam (Lexotanil) orally, 1 h before the surgical procedure
🔸Carrying out procedure in hospital
🔸Small amounts of vasoconstrictor in LA
🔸Short appointments
Ischemic necrosis of an area of the heart due to complete blocking of branches of the coronary arteries
Myocardial infarction
Myocardial infarction symptoms
🔸 Sudden onset with severe pain posterior to the sternum, which increases in severity rapidly
🔸 w/ burning sensation, pressure, and extreme tightness
🔸 More severe compared to angina pectoris, lasts longer than 15 min and does not subside with rest or use of nitrates sublingually
🔸 Radiates to the left shoulder, neck region, mandible, teeth, midback region, epigastrium, and right arm
🔸 Nausea, vomiting, perspiration, and dyspnea
Management of myocardial infarction
🔸 Avoid routine dental surgery on patients with recent infarctions (within the last 6 months)
🔸 if treatment necessary (acute infection, pain, etc.), management should take place in a hospital
🔸Six months following the myocardial infarction, patients may also be treated in the dental office- follow same precautions as Angina pectoris
Damage of the mitral and aortic valves, which may be described as stenosis, or insufficiency
Rheumatic heart disease
May develop after invasive surgical procedures and is dangerous for patients with rheumatic fever
Transient bacteraemia
Management of Rheumatic heart disease
🔸Antibiotic treatment prior to surgery
🔸Avoidance of vasoconstrictors/ maximum concentration of 1:100,000
Importance of antibiotics in Rheumatic heart disease
Transient bacteraemia after surgical procedures can affect endocardium resulting in endocarditis
Pathologic sounds due to vibrations caused by turbulence in the circulation through the vessels or chambers of the heart
Murmurs
Heart murmurs are caused by
🔸Valve defects, resulting from rheumatic disease
🔸Septic endocarditis
🔸Syphilis
🔸Congenital heart conditions
Types of murmurs
🔸Systolic
🔸Diastolic
🔸Continuous
🔸Innocent/functional- good prognosis
Management of Murmurs
🔸Establish whether murmur is functional or pathologic
🔸Antibiotic prophylaxis
Types of congenital heart disease
🔸Patent ductus arteriosus
🔸Atrial septal defects
🔸Ventricular septal defects
🔸Idiopathic pulmonary stenosis
🔸Stenosis of pulmonary or aortic valve
Management of main congenital heart diseases
🔸Consultation with physician
🔸Premedication before treatment
🔸Antibiotic prophylaxis especially in Rheumatic heart Disease
🔸Limited vasoconstrictor use
🔸Short appointments
Periodic variation in rhythm of heart caused by disturbances in the excitability of the ventricles by sinoatrial node
Arrhythmia
Management of Arrhythmia
🔸Consultation with doctor
🔸In severe cases avoidance of LA containing vasoconstrictors/ postponing treatment
🔸Premedication before surgical procedure
🔸short appointments and pain control
Management of prosthetic heart values
🔸Antibiotic prophylaxis before surgical procedure
🔸Same as valve disease of rheumatic origin
Why antibiotic prophylaxis needed in patients with prosthetic heart valves
Endocardium associated with the artificial valve is particularly susceptible to microbial infection
Used for the control of symptoms due to disturbances of the cardiac rhythm
Cardiac pacemakers
Management of patients with pacemakers
🔸 The use of certain dental instruments increases the risk of abnormal activity of the pacemaker (mono-polar electrosurgery, ultrasonic scalers, electronic dental anesthesia, etc.)
🔸 Local anesthetics with vasoconstrictors may be used safely
🔸 Antibiotic prophylaxis not required
Normal arterial pressure in an adult
-Under 140/90
-Hypertension is abnormal elevation of systolic and diastolic pressure over those values
Arterial hypertension of unknown etiology that exists in 95% of cases is named
Essential hypertension
Arterial hypertension where in 5% of cases, the cause is known is called
Secondary hypertension
High blood pressure values where treatment can be carried out
140–160/90–95 mmHg
High blood pressure values where premedication is required
🔸160–190/95–110 mmHg
🔸30mins to 1 hour before treatment
If the blood pressure values remain high even after premedication (e.g., over 180/110 mmHg)
the dental session is postponed and the patient is referred to his/her physician for further treatment
Blood pressure values where patients not allowed regular dental treatment
🔸190/110 mmHg
🔸Treated in hospital
Severe hypertension (diastolic blood pressure >140 mmHg can cause
🔸 Hypertensive encephalopathy
🔸 Papilloedema and/or retinal hemorrhage
Hypertensive encephalopathy symptoms
🔸Severe headache
🔸nausea
🔸Vomiting
🔸Confusion
🔸Convulsions and coma
In actual practice, a dentist is not meant to administer emergency antihypertensive agents, except in cases of
🔸 Repeated cases of Acute pulmonary edema
🔸Intravenous Furosemide(Lasix) administered
Management of patients with hypertension
🔸 Premedication before surgery
🔸 Blood pressure should be monitored
🔸 Aspiration during LA
🔸 Avoiding noradrenaline in patients receiving anti- hypertensive agents
🔸Short painless appointments
sudden drop in blood pressure, when patient quickly placed back to an upright position
Orthostatic hypotension
Orthostatic hypotension is caused by
disturbances of the autonomic nervous system
Second most frequently observed cause of transient loss of consciousness in the dental patient, after fainting
Orthostatic hypotension
Causes of orthostatic hypotension
🔸Not entirely known
🔸 Diabetic neuropathy
🔸Antihypertensive agents 🔸Phenothiazines
🔸Sedatives
🔸Prolonged supine position 🔸Pregnancy
🔸Extreme fatigue
Symptoms of orthostatic hypotension
🔸Drop in Bp as patient gets out of chair
🔸 Dizziness
🔸Weakness
🔸Headache
🔸Loss of balance
🔸sense of fainting
🔸 Loss of consciousness
Management of orthostatic hypotension
🔸Supporting patient as the get out of chair
🔸Monitoring of Bp
🔸Avoiding sudden changes in chair position
🔸 Evaluate medical history, especially
concerning antihypertensive agents; also, fainting episodes
Acute condition causing necrosis of brain tissue, because of intracranial hemorrhage, cerebral embolism, or thrombosis
Cerebrovascular accident (Stroke)
Symptoms of Cerebrovascular accident (Stroke)
🔸 Paralysis of one or both limbs of one side of the body
🔸Difficulty swallowing
🔸Loss of expression or inability to move facial muscles
🔸Dizziness
🔸Severe headache
🔸Perspiration
🔸Pallor
Management of Cerebrovascular accident (Stroke)
🔸Avoid treatment for 6 months following stroke/ Carry out in hospital
🔸Monitoring Bp
🔸Premedication
🔸Short painless appointments
🔸Low dose of vasoconstrictor
Important Anemias in dentistry
🔸 Aplastic anemia
🔸Biermer’s megaloblastic anemia (a type of pernicious anemia)
🔸Hypochromic anemias (iron deficiency anemia, thalassemia) 🔸Sickle cell anemia
🔸 Methemoglobinemia.
Management of patients with anaemia
🔸Thorough medical history
🔸Consultation with hematologist- hematocrit and haemoglobin levels should be as close as possible
🔸Control stress and pain
🔸Avoid abrupt manipulations especially in sickle cell anaemia
🔸Use of LA permitted except in methemoglobinemia
In patients with sickle cell disease, pain and stress may cause
Sickle cell crisis
In patients with sickle cell anaemia, abrupt manipulations during extractions can cause
Fractures in mandible due to osteoporosis caused by the disease
In methemoglobinemia the anaesthetics that are contraindicated are
Articaine and Prilocaine
Leukaemia is a pathological condition characterised by
🔸Quantitative and qualitative defects in circulating white blood cells
🔸Acute and chronic
Patients with leukaemia are susceptible to
🔸Severe infection
🔸Post operative haemorrhage
Management of patients with leukaemia
🔸Consultation with haematologist
🔸Avoid Nerve blocks if infiltrations viable
🔸Surgical procedures (extractions ect) performed in hospital
🔸In chronic leukaemia in state of remission, treatment may be carried out in dental surgery with antibiotic prophylaxis
🔸Avoid abrupt movements
Why nerve blocks should be avoided in leukaemia
Risk of hematoma
Three groups of bleeding disorders
🔸Vascular disorders
🔸Thrombocytic disorders
🔸Hemorrhagic diatheses
Disorders due to alterations of
the vascular wall, especially of the capillaries
Vascular disorders
Hereditary hemorrhagic telangiectasia or Rendu–Osler disease, Ehlers–Danlos disease, von Willebrand disease (vascular hemophilia), and congenital bleeding diseases, scurvy, and purpura due to allergy are examples of
Vascular diseases
Disorders that are due to either decreased numbers of platelets or to congenital functional abnormality of the platelets
Thrombocytic disorders
Thrombocytopenia, Glanzmann’s disease, and thrombocytosis or thrombocythemia are examples of
Thrombotic disorders
Disorders of coagulation
Hemorrhagic diatheses
hemophilias, acquired disorders of the prothrombin complex (vitamin K deficiency), severe liver disease are examples of
Hemorrhagic diatheses
Management of patients with Hemorrhagic diatheses
🔸Consultation with doctor
🔸Treatment in hospital
🔸Premedication
🔸Morning appointments(control bleeding complications)
🔸 Vasoconstrictor La for bleeding control
Conditions where anticoagulants are used
🔸 Acute myocardial infarction 🔸Vascular grafts
🔸Cerebrovascular accidents 🔸Pulmonary embolism
🔸Venous thrombosis
Most common anticoagulant drugs
🔸Coumarin
🔸Heparin
🔸Acetylsalicylic acid
Effect of Coumarin drugs
🔸 Increase the prothrombin time to 2–2.5 times above the normal level (normal range: 11– 12 s)
🔸Delay or prevent the intravascular coagulation of blood
Management of patients taking Coumarin drugs
🔸Consultation with physician to reduce or stop dose
🔸Prothrombin time reduced to 1.5 times normal value/17-19s (max)
🔸Gradual reduction of therapeutic dose 2 days beforehand
🔸Therapeutic dose increased over next 2 days after treatment
Uncomplicated dental extractions can be carried out at INR
2-3.5
INR for extensive surgical procedures should be
1.6-1.9 to reduce risk of bleeding
Management of patients taking heparin
🔸Discontinued 4h before treatment
🔸Post operative administration same day if no bleeding issues
🔸Patients on low molecular weight heparin (Clexane, Fraxiparine) don’t need to adjust dosage
Management of patients taking Aspirin
🔸Discontinued use 2-5 days prior to treatment
🔸Continue use 1 day following treatment
Alteration of the metabolism of carbohydrates, proteins, and lipids and is caused by abnormalities of the secretion mechanism and effect of insulin
Diabetes Mellitus
