PERIODONTAL MANAGEMENT OF THE MEDICALLY COMPROMISED PATIENT

Medically Compromised Patient

Patient Assessment Category I: Healthy patient Category II: Medical conditions requiring schedule changes Category III: Medical conditions requiring significant modifications in dental treatment Category IV: Medical conditions requiring major modifications in dental treatment Category V: Serious medical conditions

Systemic diseases include:

1. cardiovascular diseases 2. respiratory diseases 3. liver diseases 4. endocrine diseases 5. renal diseases 6. neurogenic diseases 7. sexually transmitted diseases 8. blood diseases 9. pregnancy & breast feeding

Main signs & symptoms of C.V.S diseases

1. Chest pain 2. Dysnea 3. cyanosis 4. palpitation 5. Syncope 6. Edema of ankles 7. Cold pale extremities 8. Clubbing fingers 9. Easy fatigue

ISCHEMIC HEART DISEASES

Mode of presentation of ischemic heart disease:
1. Angina pectoris 2. Myocardial infarction 3. Acute coronary insufficiency 4. Cardiac arrhythmia 5. Heart failure 6. Sudden death ( cardiac arrest, ventricular fibrillation ) 7. Asymptomatic ( silent )

ANGINA PECTORIS
It is a myocardial ischemia resulting from imbalance between coronary blood flow & oxygen demand

PERIODONTAL MANAGENT OF ANGINA:

1. Medical consultation 2. Appointment 3. Reduction of stress & anxiety 4. Local anesthesia 5. General anesthesia 6. Treatment procedures

7. Drugs used in treatment

8. If the attack developed

MYOCARDIAL INFARCTION
It results from occlusion of coronary artery By a thrombus so deficient coronary arterial blood supply to a region of myocardium that results in a cellular death & necrosis.

Periodontal management:
As angina pectoris except; Drugs used in treatment.

CONGESTIVE HEART FAILURE

It is the ability of heart to pump sufficient blood to meet the metabolic needs of the heart.

Periodontal management:
Same as angina except; 1.preoperative antibiotic. 2. Drugs used in treatment. 3. Management of complications if developed (attack)

HYPERTENSIVE DISEASES
Hypertension is used to describe patient with blood pressure more than 140/90 mmHg

Periodontal management:
Same as angina except; 1. Local anesthesia. 2. General anesthesia. 3. treatment procedure.

RHEUMATIC HEART DISEASE

It is an acute inflammatory condition, due to strep. Pharngitis infection following sore throat, result in scaring & calcification of valves followed by valvular stenosis. Periodontal management.
1. Medical consultation.

2. Prophylactic antibiotic. 3. Mild tranquilizers (2-5 diazepam). 4. Short dental appointment.

PROPHYLACTIC ANTIBIOTIC REGIMEN FOR CARDIAC PT.

1. Under L.A a) Adults---- 2gm Amoxicillin or 2gm
Ambicillin (1 hour before treatment orally) OR (1/2 hour ,,, ,,,,,,,,,,, injection) B) Children----- 50 mg per Kg Amoxicillin or Ambicillin

IF PATIENT IS ALLERGIC:

Adult --------- Clindamycin 600 mg OR Asathromycin 500 mg OR Cephazolin 1 gm (1 hour before ttt. Orally) ( ,,, ,,,, ,,, injection)

Child --------- Clindamycin 20 mg per Kg. Asathromycin 15 mg per Kg.

2. Under G.A
a)Adults----- 1gm Amoxicillin I.V at induction.
OR 3gm Amoxicillin orally 4 hours before induction followed by 3gm Amoxicillin immediately after recovery. OR 300mg Clindamycin I.M hour before induction. OR 300mg Clindamycin I/V at induction

b) Children ------ (510 years)1/2 adult

(< 5 years) 1/4 adult

RESPIRATORY DISORDERS
Common symptoms:
1. cough. 2. wheezing. 3. cyanosis. 4. finger clubbing. AVOID 1. General anesthesia: leads to hypoxia . 2. Analgesics & narcotics: leads to respiratory depressants.

BRONCHIAL ASTHMA
It is due to bronchospasm or hyperirritability of the tracheo_bronchial tree. Patient is treated by: 1. Corticosteroids inhalators. 2. Bronchodilator. 3. Beta adrenergic stimulator.

Periodontal management
1. Medical consultation.

2. stress & anxiety.

3. Local anesthesia.
4. General anesthesia.

5. Drugs used in treatment.

6. Drugs given to patient.

TUBERCULOSIS
Can affect any organ. Highly infectious. Caused by Mycobacterium T.B. Transmitted by air born droplets.

Periodontal management:
1. Patient with active T.B.

2. Patient with past history of T.B. 3. Patient with positive tuberculin test.

4. Patient with signs & symptoms of T.B.

5. Strict aseptic technique.

LIVER DISORDERS
Advanced liver diseases include: Liver cirrhosis - Jaundice

Potential complications: 1. Impaired drug detoxication e.g. sedative, analgesics, general anesthesia. 2. Bleeding disorders ( decrease clotting factors, excess fibrinolysis, impaired vitamin K absorption). 3. Transmission of viral hepatitis.

Periodontal management
1. Medical consultation. 2. Avoid drugs metabolized in liver: L.A------- Lidocaine, Mepicaine Sedatives-------- Valium antibiotics-------- Ampicillin Analgesics------- Aspirin 3. Vit.k ----- 10 mg/day before surgery. 4. G.A ------ cause bleeding.

VIRAL HEPATITIS
Periodontal management:
1. Patient with active hepatitis 2. Carriers: a. low risk patient. b. high risk patient.

DIABETUS MELLITUS
It is characterized by persistent increase of blood glucose level. It is the result of absolute or relative deficiency of insulin.

 Oral manifestation:
1. Gingivitis 2. Alveolar bone resorption 3. Xerostomia 4. Delayed wound healing 5. Pulpitis in non carious tooth 6. Burning sensation in tongue 7. Acetone smell in breath

Periodontal management:
1. Appointment.

2. Premeditation
3. Local anesthesia. 4. Treatment procedure.
5. Patient assessment.

CHRONIC RENAL FAILURE

Periodontal management:
1. Patient with conservative treatment. 2. Patient with hemodialysis. 3. Patient with kidney transplant. 4. Emergency treatment.

THYROID GLAND DISORDER

Periodontal management:
1. Uncontrolled or poorly controlled patient 2. patient with thyrotoxicosis. Antithyroid drugs may couse leucopenic aplastic anemia.

Management of thyroid crises

1. Ant thyroid drugs 2. Hydrocortisone 3. I.V. glucose 4. Oxygen administration 5. Cooling to decrease temp. of body.

NEUROGENIC DISORDER (EPILEPSY)

Neurogenic disorder: is disorder of the brain. Epilepsy: is the most common neurogenic disorder the dentist may face in his clinic.

Potential problems:
1. Precipitation of the attack. 2. Problems of drugs taken a) Dilantin------- gingival hyperplasia b) Depakene------- bleeding tendancy

Periodontal management:
1.Past medical history.
2.In case of controlled patient.

3.In case of uncontrolled patient.

4.Management of attack if developed.

N.B:

Dentist is no longer treating teeth in patients, but rather patients who have teeth.

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