Dental management of medical compromised patients

Infective Endocarditis :
Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or heart valves that most often occurs in proximity to congenital or acquired cardiac defects. A clinically and pathologically similar infection that may occur in the endothelial lining of an artery, usually adjacent to a vascular defect (e.g., coarctation of the aorta) or a prosthetic device (e.g., arteriovenous [AV] shunt), is called infective endarteritis . Although bacteria most often cause these diseases, fungi and other microorganisms may also cause infection; thus, the term infective endocarditis (IE) is used to reflect this multimicrobial origin. The term bacterial endocarditis (BE) commonly is used, reflecting the fact that most cases of IE are due to bacteria. IE is a disease of significant morbidity and mortality that is difficult to treat; therefore, emphasis has long been directed toward prevention. Historically, various dental procedures have been implicated as a significant cause of IE because the oral flora is frequently found to be the causative agent. Furthermore, whenever a patient is given a diagnosis of IE caused by oral flora, dental procedures performed at any point within the previous several months have typically been blamed for the infection. As a result, antibiotics have been administered prior to certain invasive dental procedures in an attempt to prevent infection. It is of note, however, that the effectiveness of this practice 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, and positive blood culture, although the clinical presentation may be varied. It is of particular significance that the interval between the presumed initiating bacteremia and the onset of symptoms of IE is estimated to be less than 2 weeks in more than 80% of patients with IE. In many cases of IE that have been purported to be due to dentally induced bacteremia, the interval between the dental appointment and the diagnosis of IE has been much longer than 2 weeks (sometimes months), and thus it is very unlikely that the initiating bacteremia was associated with dental treatment. Dental Procedure/Oral Manipulation Reported Frequency of Bacteremia: Tooth extraction Periodontal surgery Scaling and root planing Teeth cleaning Rubber dam matrix/wedge placement Endodontic procedures Toothbrushing and flossing Use of wooden toothpicks Use of water irrigation devices Chewing food Efficacy of Antibiotic Prophylaxis: The assumption that antibiotics given to at-risk patients prior to a dental procedure will prevent or reduce a bacteremia that can lead to IE is controversial. Some studies report that antibiotics administered prior to 10%-100% 36%-88% 8%-80% 40% 9%-32% 20% 20%-68% 20%-40% 7%-50% 7%-51%

a dental procedure reduced the frequency, nature, and/or duration of bacteremia, although others did not. Recent studies suggest that amoxicillin therapy has a statistically significant impact on reducing the incidence, nature, and duration of bacteria associated with dental procedures, but it does not eliminate bacteremia. However, no data show that such a reduction caused by antibiotic therapy reduces the risk of or prevents IE. DENTAL MANAGEMENT Antibiotic Prophylaxis: Dental treatment has long been implicated as a significant cause of IE. Conventional wisdom has taught that in a patient with a predisposing cardiovascular disorder, IE was most often due to a bacteremia that resulted from an invasive dental procedure, and that through the administration of antibiotics prior to those procedures, IE could be prevented. Based on these assumptions, over the past 50 years, the AHA published nine sets of recommendations for antibiotic prophylaxis for dental patients at risk for . These recommendations, first put forth in 1955 and revised every few years, varied in terms of identification of risk conditions, selection of antibiotics, timing of antibiotic administration, and route of administration of antibiotics. It is important to recognize that although these recommendations were a rational and prudent attempt to prevent life-threatening infection, they were largely based on circumstantial evidence, expert opinion, clinical experience, and descriptive studies in which surrogate measures of risk were used. Furthermore, the effectiveness of theserecommendations has never been proved in humans. 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, for a lengthy appointment, this may be a matter of concern. With amoxicillin, which has a half-life of approximately 80 minutes, the average peak plasma concentration of 4 g/mL is reached about 2 hours after oral administration of a 250-mg dose.

Most of the penicillin-sensitive viridans group streptococci have an MIC requirement of 0.2 g/mL. Thus, it would appear that a 2-g dose of amoxicillin would produce an acceptable MIC for at least 6 hours. 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 or walking) Report of weight gain or increased abdominal girth (fluid accumulation; ascites) Anorexia, nausea, vomiting, (bowel edema) Hyperventilation followed by apnea during sleep Heart murmur Other manifestation related to drugs: Lesions

Dry mouth ascites

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 not tolerate a supine chair position because of pulmonary edema and will need a semisupine or upright chair position.) anesthesia is without adrenaline.

Ischemic Heart Disease:

Coronary atherosclerotic heart disease is a major health problem in the United States and in other industrialized nations. Atherosclerosis is the thickening of the intimal layer of the arterial wall caused by the accumulation of lipid plaques. The atherosclerotic process results in a narrowed arterial lumen with diminished blood flow and oxygen supply. Atherosclerosis is the most common underlying cause of not only 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 often referred to as ischemic heart disease. Ischemic symptoms are the result of oxygen deprivation caused by reduced blood flow to a portion of the myocardium. Other conditions such as embolism, coronary ostial stenosis, coronary artery spasm, and

congenital abnormalities also may cause ischemic heart disease.

CLINICAL PRESENTATION: Symptoms: Chest pain is the most important symptom of coronary atherosclerotic heart disease. The pain may be brief, as in angina pectoris resulting from temporary ischemia of the myocardium, or it may be prolonged, as in unstable angina or AMI. Ischemic myocardial pain results from an imbalance between the oxygen supply and the oxygen demand of the muscle. Atherosclerotic narrowing of the coronary arteries is an important cause of this imbalance. The exact mechanism or agents involved in producing the cardiac pain are not known.

DENTAL MANAGEMENT:
Medical Considerations Risk assessment for the dental management of patients with ischemic heart disease involves three determinants: 1. Severity of the disease 2. Type and magnitude of the dental procedure 3. Stability and reserve of the patient Dental Management Considerations for Patients With Unstable Angina or Recent Myocardial Infarction [*] Avoid elective care If treatment is necessary, consult with physician and limit treatment to pain relief, treatment of acute 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 with above measures * Myocardial infarction within the past 30 days.

Dental Management Considerations for Patients With Stable Angina or Past History of Myocardial 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 night before 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 with coronary artery stents Antibiotic prophylaxis not recommended for history of coronary artery 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 least 4 to 6 weeks should elapse after an uncomplicated MI before elective procedures are performed. The use of vasoconstrictors in local anesthetics poses potential problems for patients with ischemic heart

disease because of the possibilities of precipitating cardiac tachycardias, arrhythmias, and increases in blood pressure. Local anesthetics without vasoconstrictors may be used as needed. If a vasoconstrictor is necessary, patients with intermediate risk and those taking nonselective beta blockers can safely be given up to 0.036 mg epinephrine (2 cartridges containing 1:100,000 epi) or 0.20 mg levonordefrin (2 cartridges containing 1:20,000l evo); intravascular injections are avoided. Greater quantities of vasoconstrictor may well be tolerated, but increasing quantities increase the risk of adverse cardiovascular effects. For patients at higher risk, the use of vasoconstrictors should be discussed with the physician. Studies have shown, however, that modest quantities of vasoconstrictors may be used safely even in high-risk patients when accompanied by oxygen, sedation, nitroglycerin, and excellent pain control measures. For patients at all levels of cardiac risk, the use of gingival retraction cord impregnated with epinephrine should be avoided because of the rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects. As an alternative, plain cord saturated with tetrahydrozoline HCl 0.05% (Visine; Pfizer Inc, New York, NY) or oxymetazoline HCl 0.05% (Afrin; Schering-Plough, Summit, NJ) provides gingival effects equivalent to those of epinephrine without adverse cardiovascular effects. Patients who take daily aspirin (160 to 325 mg) can expect some increase in surgical and postoperative bleeding, but this is generally not clinically significant and can be controlled with local measures only. Discontinuation of these agents before dental treatment generally is unnecessary.

Arrhythmia:

An irregular heartbeat is an arrhythmia (also called dysrhythmia). Heart rates can also be irregular. A normal heart rate is 50 to 100 beats per minute. Arrhythmias and abnormal heart rates don't necessarily occur together. Arrhythmias can occur with a normal heart rate, or with heart rates that are slow (called bradyarrhythmias -- less than 50 beats per minute). Arrhythmias can also occur with rapid heart rates (called tachyarrhythmias -faster than 100 beats per minute). In the United States, more than 850,000 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 of injected epinephrine may lead to lifethreatening cardiac arrhythmias in susceptible dental patients. Patients with an existing arrhythmia, diagnosed or undiagnosed, are at increased risk in the dental environment. In addition, patients at risk for developing an arrhythmia may be in danger in the dental office if they are not identified and measures are not taken to minimize stressful situations that can precipitate an arrhythmia. 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 dental management of patients prone to developing a cardiac arrhythmia and those with an existing arrhythmia are identification and prevention. Even under the best of circumstances, however, a patient may develop a cardiac arrhythmia that requires immediate emergency measures. Identification of patients with a history of an arrhythmia, those with an undiagnosed arrhythmia, and those prone to developing one is the first step in risk assessment and in avoiding 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, blood pressure, respiratory rate). In a review of systems, patients should be asked about the presence of signs or symptoms related to the cardiovascular and pulmonary systems. Patients who report palpitations, dizziness, chest pain, shortness of breath, or syncope may have a cardiac arrhythmia or other cardiovascular disease, and should be evaluated by a physician. Patients with an irregular cardiac rhythm (even without symptoms) also may require consultation with the physician to determine its significance. Patients with a known history of arrhythmia should be questioned as to the type of arrhythmia (if known),

how it is being treated, medications being taken, presence of a pacemaker or defibrillator, effects on their activity, and stability of their disease. Because the classification and diagnosis of arrhythmia are often complex, patients often do not know the specific diagnosis that has been assigned to their disorder; thus, the physician must be relied upon to provide this information. It is important to identify any known triggers, such as stress, anxiety, or medications. Patients with a history of other heart, thyroid, or chronic pulmonary disease should be identified, as these may be a cause of or contributor to the arrhythmia, and they may require special management as well. If any questions or uncertainties arise, a medical consultation should be sought regarding patient diagnosis and current status, and to aid the dentist in assessing risk for aggravating or precipitating a cardiac arrhythmia, stroke, or MI during or in relation to dental treatment. The dentist must make a determination of the risk involved in providing dental treatment to a patient with a history of arrhythmia and must decide whether the benefits of treatment outweigh any risk. This often requires consultation with the physician. have published guidelines that can help to make this determination. These guidelines are intended for use by physicians who are evaluating patients with cardiovascular disease to determine whether they can safely undergo surgical procedures. They also may 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 With Cardiac 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 of previous myocardial infarction) Dental Management: Elective dental care OK. ARRHYTHMIAS ASSOCIATED WITH MINOR PERIOPERATIVE RISK 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 Patients With Cardiac Arrhythmias

STRESS AND ANXIETY REDUCTION Establish good rapport Schedule short, morning appointments Ensure comfortable chair position Provide preoperative sedation (short-acting benzodiazepine night before 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 1:100,000 concentration). 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 surgical procedure) If INR is within the therapeutic range (INR, 2.0-3.5), dental treatment, including minor oral surgery, can be performed without stopping or altering the Coumadin Local measures include gelatin sponge or oxidized cellulose in sockets, suturing, gauze pressure packs, preoperative stents, and tranexamic acid or aminocaproic acid mouth rinse and/or to soak gauze

FOR PATIENTS WITH PACEMAKERS: Antibiotic prophylaxis to prevent bacterial endocarditis is not recommended 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 URGENT CARE, 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 pressure that can be fatal if sustained and untreated. People with hypertension may not display symptoms for many years but eventually can experience symptomatic damage to several target organs, including kidneys, heart, brain, and eyes. In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained diastolic blood pressure of 90 mm Hg or greater is defined as hypertension. The dental health professional can play a significant role in the detection and control of hypertension and may well be the first to detect a patient with an elevation in blood pressure or with symptoms of hypertensive disease. Along with detection, monitoring is an equally valuable service because patients who are receiving treatment for hypertension but may not be adequately controlled because of poor compliance or inappropriate drug selection or dosing. The dental patient with hypertension poses several potentially significant management considerations. These include identification of disease, monitoring, stress and anxiety 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-term steroid 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 Patients With 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 taking non-selective b-beta blockers or peripheral adrenergic antagonists Avoid the use of epinephrine-impregnated gingival retraction cord Consider periodic intraoperative BP monitoring for patients with upper level stage 2 hypertension; terminate appointment if BP rises above 179/109 Slow position changes to prevent orthostatic hypotension BP, Blood pressure.