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Managing Dental Patients with Medical Problems

Managing Dental Patients with Medical Problems. Dayton W. Daberkow II MD Leonard J. Chabert Internal Medicine Residency Program Director Houma, Louisiana. Diabetes.

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Managing Dental Patients with Medical Problems

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  1. Managing Dental Patients with Medical Problems Dayton W. Daberkow II MD Leonard J. Chabert Internal Medicine Residency Program Director Houma, Louisiana

  2. Diabetes 45 year old male with history of diabetes type 2 on Glargine (Lantus) 30 units at bedtime and has a dental procedure in the morning. 20 minutes after the procedure the patient tells the nurse he fells very weak, his right arm is weak and his fingers are tingling. What do you recommend at this time? • Contact EMS to transfer to emergency room for a stroke work-up. • Make sure the patient is laying down and check on him in 30 minutes. • Check the blood glucose with a glucometer. • Give a rapidly absorbed form of 15 grams of a carbohydrate.

  3. Diabetes If the patient is unable to take anything by mouth, has an IV line and his glucose is 30 you should: • Recheck the glucose in 20 minutes to make sure it is low before initiating any treatment. • Administer 1 amp of D50 solution (25 to 50 mL of a 50% dextrose solution). • Administer 1 amp of bicarbonate • Administer 5 mg of Glucagon

  4. Diabetes If the patient does not have an IV then do the following if hypoglycemic: • Administer 1 mg of glucagon IM or SQ at any body site. • Administer 1 mg of epinephrine IM or SQ • Administer 1 amp of D50 under the tongue • Administer 1 mg of glucagon under the tongue

  5. Management of hypoglycemia in the office • Signs and symptoms: confusion, tremors, sweating, agitation, anxiety, dizziness, tingling or numbness, and tachycardia. Severe hypoglycemia may result in seizures or loss of consciousness. • Immediately check blood sugar with a glucometer. • If no glucometer available assume HYPOGLYCEMIA with above symptoms. Hyperglycemia can have some of these same symptoms but hypoglycemia more dangerous.

  6. Type 2 diabetes treated with oral hypoglycemic agents 55 y/o female with history of diabetes type 2 will have a dental procedure in the morning. She takes metformin twice a day. She will be not eating breakfast before the procedure. You advise her to do the following: • Take the morning dose of her metformin. • Hold morning dose of metformin, resume evening dose if eating. • Hold morning dose of metformin and double the dose at bedtime. • Hold both morning and evening dose of metformin.

  7. Type 2 diabetes treated with oral hypoglycemic agents • Sulfonylureas increase the risk of hypoglycemia • DPP-IV inhibitors (gliptins) and GLP-1 analogs (incretins) could alter GI motility • Metformin is contraindicated in conditions that increase the risk of renal hypoperfusion, lactate accumulation and tissue hypoxia • Therefore, hold all oral hypoglycemic agents before procedures that require morning fasting. If no fasting, patient may take oral hypoglycemics with careful glucose monitoring.

  8. Type 1 or insulin treated type 2 diabetes 35 male with history of diabetes type 2 is scheduled for a dental procedure the next day. He takes 25 units of Glargine (long acting insulin) nightly and 6 units of Novolog (rapid acting) with each meal. He will be NPO before the procedure. You recommend: • Hold Glargine and Novolog and resume the evening after the procedure. • Hold Glargine but begin and insulin infusion in the office. • Continue Glargine the night before procedure and give ½ dose of Novolog in the morning. • Continue Glargine the night before procedure and hold Novolog until patient eating.

  9. Type 1 or insulin treated type 2 diabetesFor minor morning procedures: • Generally patients who use insulin can continue with their subcutaneous insulin for procedures that are not long and complex. • If the patient has borderline hypoglycemia or "tight" control of the fasting blood glucose, reduce the night time (supper or HS) long or intermediate acting insulin on the night prior to surgery to prevent hypoglycemia. • Type 1 diabetes can develop ketoacidosis if they take no insulin even they are NPO. Their basal metabolic needs when fasting require at least ½ their usual insulin requirements. • Hold short-acting insulin until eating.

  10. Type 1 or insulin treated type 2 diabetes For Procedures that are long or take place later in day where both breakfast and lunch are missed: • If insulin (both intermediate and short-acting insulin) taken only in morning, give one-half their total morning insulin to provide basal insulin during the procedure and prevent ketosis • Hold short-acting insulin morning of procedure if also on long acting insulin. • For patients who take insulin two or more times per day, give between one-third to one-half of the total morning dose (both intermediate and short-acting insulin) as intermediate acting insulin only • Patients on continuous insulin infusion may continue with their usual basal infusion rate. Start dextrose containing intravenous solution.

  11. Biphosphonates and Dental Surgery Osteonecrosis of Jaw (ONJ) • Risk factors include invasive dental procedures (eg, tooth extraction, dental implants, boney surgery); a diagnosis of cancer, with concomitant chemotherapy or corticosteroids; poor oral hygiene, ill-fitting dentures; and comorbid disorders (anemia, coagulopathy, infection, pre-existing dental disease). • Most cases after IV but some reports of oral therapy. • Manufacturer recommends discontinuing bisphosphonates in patients requiring invasive dental procedures. No real evidence this prevents ONJ.

  12. Blood Pressure Management 60 year-old-male with a history of hypertension is scheduled for a dental procedure. His past history and physical examination are unremarkable. He takes Verapamil 240 mg every day and his blood pressure in the office was 130/80. Which of the following is the best strategy for preoperative evaluation • Schedule an exercise stress test • Echocardiogram • Hold blood pressure pill before surgery • Take blood pressure pill AM of surgery

  13. Blood Pressure Management 55 year-old-female with a history of hypertension is scheduled for a dental procedure. Past history and PE are unremarkable. She takes HCTZ 25 mg every AM and office blood pressure is 200/120. Which of the following would be the best management? • Take HCTZ am of surgery and proceed to surgery. • Delay surgery and add another BP pill to get diastolic blood pressure less than 110 mm Hg. • Delay surgery and increase dose of HCTZ to get diastolic blood pressure less than 80.

  14. Blood Pressure Management • Elective surgery/procedures should be postponed in patients with blood pressures above 170/110 mmHg • Take all blood pressure pills with sip of water morning of procedure • Continue antihypertensive treatment throughout procedures, especially drugs like Clonidine and Beta- blockers to avoid severe post procedure hypertension.

  15. Hypertensive Emergencies • Repeat BP in both arms and again 10 minutes later and make sure the cuff size is the appropriate size (bag length 80% of limb circumference) • For severe hypertension systolic BP > 200 or diastolic BP > 120 assess whether the elevated BP is causing target organ damage • Assess neurologic, cardiac, renal function and retinas • Patients with evidence of target organ damage should be admitted to an ICU with invasive monitoring and parenteral antihypertensive therapy • Don’t lower BP aggressively if there are focal neurological signs; don’t allow diastolic BP to fall below 100 mm Hg

  16. Endocarditis Prophylaxis 26 year-old-male with a history of mitral valve prolapse with regurgitation 1. Amoxicillin 2.0 grams orally 1 hour before surgery (1997 AHA guidelines) 2. No prophylaxis needed (2007 AHA guidelines) 3. Amoxicillin 1.0 gram orally 1 hour before surgery 4. Amoxicillin 1.0 gram orally 1 hour before and 1.0 gram after surgery

  17. Endocarditis Prophylaxis 65 year-old-male with a history of a prosthetic mitral valve who’s jaw is broken and can’t swallow. 1. No prophylaxis needed 2. Amoxicillin 2.0 grams orally 1 hour before surgery 3. Ampicillin 2.0 grams IM/IV 30 minutes before surgery 4. Ampicillin 2.0 grams IM/IV 3 hours before and 1 hour after surgery

  18. Endocarditis Prophylaxis 44 year-old-female with a previous history of endocarditis who is allergic to penicillin 1. No prophylaxis needed 2. Cephalexin 500 mg 1 hour before surgery 3. Clindamycin 600 mg orally 1 hour before surgery 4. Azithromycin or Clarithromycin 500 mg orally 1 hour before surgery 5. 2 or 3 6. 3 or 4

  19. Endocarditis Prophylaxis 50 year-old-female with a history of hypertrophic cardiomyopathy who is allergic to penicillin and can’t swallow 1. No prophylaxis needed (2007 AHA guidelines) 2. Vancomycin 1.0 gram IV 1-2 hours, complete infusion before surgery 3. Cephalexin 1.0 gram IV 30 minutes before surgery 4. Clindamycin 600 mg IV 30 minutes before surgery (1997 AHA guidelines)

  20. Cardiac Conditions Associated With Endocarditis Endocarditis Prophylaxis Recommended for High-risk categories: • Prosthetic cardiac valves, including bioprosthetic and homograft valves • Previous bacterial endocarditis • Complex cyanotic congenital heart disease (e.g.. Single ventricle states, transposition of the great arteries, tetralogy of Fallot) • Surgically constructed systemic pulmonary shunts or conduits • Cardiac Transplant with new valvulopathy

  21. Cardiac Conditions Associated With Endocarditis No Prophylaxis Recommended (2007 AHA Guidelines) Moderate risk category: Most other congenital cardiac malformations (other than high-risk) • Acquired valvular dysfunction (e.g.. Rheumatic heart disease AI, AS, MS, MI) • Hypertrophic cardiomyopathy • Mitral valve prolapse with valvular regurgitation and/or thickened leaflets • Cardiac Stents first 30 days? Endothelialized

  22. Endocarditis Prophylaxis Not Recommended Negligible-risk category (no greater risk than the general population) • Isolated secundum atrial septal defect • Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months) • Previous coronary artery bypass graft surgery • Mitral valve prolapse without valvular regurgitation • Physiologic, functional, or innocent heart murmurs • Previous rheumatic fever without valvular dysfunction • Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

  23. Dental Procedures and Endocarditis Prophylaxis Endocarditis Prophylaxis Recommended: • Dental extractions • Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance • Dental implant placement and reimplantation of avulsed teeth • Endodontic (root canal) instrumentation or surgery only beyond the apex • Subgingival placement of antibiotic fibers or strips • Initial placement of orthodontic bands but not brackets • Intraligamentary local anesthetic injections • Prophylactic cleaning of teeth or implants where bleeding is anticipated

  24. Prophylaxis recommended • All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. • For patients only in the HIGH RISK category

  25. Prophylactic Regimens for Dental, Oral, Procedures Situation AgentRegimen Standard general Amoxicillin Adults 2.0g; children 50 prophylaxis mg/kg orally 1 hr before procedure Unable to take oral meds Ampicillin Adults 2.0g intra- muscular (IM) or intravenously (IV); children: 50 mg/kg IM or IV within 30 min before procedure

  26. Prophylactic Regimens for Dental, Oral, Procedures Situation AgentRegimen Allergic to penicillin Clindamycin Adults 600 mg; children: 20 mg/kg orally 1 hr before procedure Azithromycin, Adults 500 mg; Clarithromycin children 15 mg/kg orally 1 hr before procedure

  27. Prophylactic Regimens for Dental, Oral, Procedures SituationAgentRegimen Allergic to penicillin Clindamycin Adults: 600 mg and unable to take IM/IV; before procedure children 20 mg/kg IM IV within 30 minutes

  28. Endocarditis Prophylaxis For patients having surgery, which of the following cases requires Endocarditis prophylaxis: (yes/no) 1. 26F with a hx of MVP w/o regurgitation 2. 40F with a physiologic/innocent heart murmur 3. 60M with a hx Endocarditis 4. 55M who has a systolic murmur that increases with valsalva and echocardiogram shows a thickened septum 5. 70F with a prosthetic aortic valve 6. 70F with a hx of CABG 2 months ago 7. 66M who had a cardiac pacemaker for SSS 8. 66M s/p repair of an atrial septal defect

  29. Prosthetic Joints • Prosthetic joints in > 2 years and no immunocompromising states no antibiotic prophylaxis. • Prosthetic joints in < 2 years and immunocompromised maybe antibiotic prophylaxis.

  30. Cardiac Conditions and Dental Procedures 62-year-old man with history of CABG 3 years ago is scheduled for a dental procedure. No other medical problems and physical examination is unremarkable. What historical information will best help you in managing this patient? 1. No headaches or dizziness 2. No shortness of breath (SOB) while sleeping 3. No chest pain or SOB at rest 4. No chest pain or SOB after walking up a flight of stairs

  31. Cardiac Conditions and Dental Procedures This same 62 year-old-man with a history of a CABG had chest pain over the past month that occurred with ambulation after one block and has been increasing in severity, duration, and frequency over the past 1 week. What is the best preoperative strategy? 1. Take nitroglycerin before dental procedure 2. Echocardiography 3. Proceed to dental procedure with no action 4. Cancel dental procedure and refer back to PCP or cardiologist

  32. Cardiac Conditions and Dental Procedures A 38 male is scheduled for a dental procedure. His physical examination revealed a jugular venous pressure of 8 cm, an S3 gallop, and bilateral crackles? He also says that he has had progressive SOB over that past 3 weeks? 1. Proceed to dental procedure 2. Coronary angiogram to decrease risk 3. Delay surgery and medically manage until the CHF has resolved

  33. Cardiac Conditions and Dental Procedures 55 year old female is scheduled for a dental procedure. She has a history of atrial fibrillation on no anticoagulation. She has had palpitations over past 2 weeks, is on metoprolol 25 mg twice a day and office heart rate is 120. You recommend: • Cancel procedure and refer to PCP for management of her atrial fibrillation and better heart rate control < 110 • Proceed with procedure as long as heart rate < 130 • Administer digoxin 0.25 mg in the office and have the patient stay until heart rate < 90

  34. Active Cardiac Conditions for which patients should undergo evaluation and treatment before Non-cardiac Surgery • Unstable Coronary Syndromes Unstable or severe angina (CCS Class III or IV). Recent MI (more than 7 d less than 1 month). • Decompensated HF NYHA functional class IV; worsening or new-onset HF.

  35. Congestive Heart Failure Systolic Dysfunction Pharmacological Management • Diuretic - Furosemide 20-80 mg per day (200 mg in CRI). Best to give at 4-6 PM when volume status highest. • Spironolactone 25-100 mg BID • Angiotensin Converting Enzyme (ACE) inhibitor at bedtime (captopril, enalapril). Titrate to the largest tolerated dose. • Beta-Blockers with meals. • Discontinue ACE inhibitors if the serum potassium is >5.5 meq per L that cannot be reduced, sx hypotension, or hx of adverse reaction • Hydralazine/isosorbide dinitrate is an alternative for ACE inhibitors or ARB’s (Angiotensin II receptor blockers i.e. losartan) • Digoxin • Monitor electrolytes, control blood pressure • Avoid NSAIDS and COX-2 inhibitors

  36. Active Cardiac Conditions for which patients should undergo evaluation and treatment before Non-cardiac Surgery 3. Significant Arrhythmias • High grade AV block • Mobitz Type II AV block • 3rd degree AV block • Symptomatic ventricular arrhythmias • Supraventricular arrhythmias (atrial fibrillation with uncontrolled rate, HR greater 110 at rest) • Symptomatic bradycardia • Newly recognized ventricular tachycardia

  37. Active Cardiac Conditions for which patients should undergo evaluation and treatment before Non-cardiac Surgery • Severe Valvular Disease: Aortic Stenosis severe (mean pressure gradient > 40 mm Hg, aortic valve area < 1.0 cm2, or symptomatic) Mitral Stenosis Symptomatic (progressive dyspnea on exertion, exertional presyncope, or HF)

  38. Cardiac Risk for Non-cardiac Surgical Procedures Low (<1% cardiac risk)* Dental procedures Breast surgeries Endoscopic procedures Superficial procedures Cataract operation Ambulatory surgery *combined incidence of cardiac death and nonfatal MI.

  39. Noncardiac Surgery and medicines Perioperative Statin therapy: Protective effect on cardiac complications, therefore, continue through surgery/procedure. Alpha-2 Agonists: Clonidine has minimal hemodynamic effects and reduced postoperative mortality for up to 2 years. Continue through surgery/procedure Perioperative Calcium Channel Blockers: Reduced ischemia and supraventricular tachycardia and death and MI. Continue through surgery/procedure.

  40. Lung Disease and Dental Procedures A 25 year old male with history of asthma is scheduled for a dental procedure. What questions are important to ask him to assess the status of his asthma? • What medicines are you currently taking? • Do you have any pets in the house? • Have you had any of the following, cough, wheezing, shortness of breath, chest pain over the past 2 weeks? • Did you get your flu shot this year? • 1,2 and 4 • 1 and 3

  41. Lung Disease and Dental Procedures A 32 year old female with a history of Asthma is scheduled for a dental procedure. She takes fluticasone/salmeterol (100/50) 1 puff twice a day and an albuterol inhaler 2 puffs as needed daily. She has had to use her albuterol 4 times a day over the last week because of a lingering cough. You recommend: • Advise to stop the albuterol since it is making her cough worse. • Proceed with dental procedure since it will be less than 1 hour and no drugs will be used to affect her asthma • Send to ER immediately • Cancel procedure and refer to PCP to assess asthma

  42. Lung Disease and Dental Procedures Two weeks later this same 32 female is scheduled for her dental procedure. Her PCP increased her fluticasone/salmeterol to (200/50). She wants to get the procedure done and said the cough is better but does get short of breath twice a day and has had some chest pain. What test below would provide the most information about the current state of her asthma? • Pulmonary function studies. • Chest X-ray • Peak flow meter reading in the office • Arterial blood gas

  43. Lung Disease and Dental Procedures Severe Persistent Asthma • Symptoms throughout the day • Nocturnal symptoms frequent • Nocturnal awakenings nightly • Need for short-acting beta agonists for symptom relief several times per day • Peak flow rate: < 60% predicted

  44. Lung Disease and Dental Procedures Severe Persistent Asthma Treatment: • Medium to High-dose Inhaled Corticosteroids (ICS) and Long-acting Beta-2 agonist (LABA) • Omalizumab an anti-IgE therapy may be considered if there is objective evidence of allergies i.e. allergy skin tests • Oral corticosteroids as needed for severe symptoms

  45. Lung Disease and Dental Procedures Potential Risk Factors Asthma Maximize control before any procedure/surgery • No cough, SOB, wheezing • Peak flow greater than 80% predicted or personal best value • Pulmonary Exam should be free of wheezes

  46. Lung Disease and Dental Procedures 65 y/o M with history of COPD is scheduled for a dental procedure. He takes ipratropium bromide inhaler 2 puffs twice a day and a short-acting Beta-agonist 2 puffs twice a day. He has a non-productive cough that has been increasing the past 2 weeks. Lung exam reveals bilateral wheezes. Management before procedure: a. Increase both inpratropium bromide and the short-acting beta-agonist b. Begin antibiotics c. Get pulmonary function tests prior to surgery d. Perform procedure

  47. Lung Disease and Dental Procedures After 2 weeks of maximizing his inhalers by his PCP he still has a non-productive cough and SOB that is worse than 4 weeks ago. On lung exam he has bilateral wheezes that haven’t changed. The chest x-ray shows no infiltrate/pneumonia. Management: a. Proceed to procedure/surgery b. Begin Antibiotics c. Steroids-Prednisone 40 mg in AM for 7-10 days

  48. Lung Disease and Dental Procedures 55 y/o M with a history of COPD is scheduled for a dental procedure. He takes ipratropium bromide 2 puffs twice a day. Over the past 10 days he has had increasing SOB and a cough with productive sputum. On exam he has bilateral decreased breath sounds. What do you recommend? a. Cancel procedure and follow-up with PCP and get pulmonary function tests b. Send to ER and get a stat EKG c. Cancel procedure follow-up with PCP and get a Chest x-ray d. Proceed to procedure

  49. Lung Disease and Dental Procedures The chest x-ray showed no infiltrates/pneumonia. What do you think his PCP would be adding for further management before the dental procedure? a. Add short-acting beta-2 agonist b. Prednisone 40 mg for 7 days c. Continue ipratropium bromide inhaler d. Antibiotics e. All of the above

  50. Lung Disease and Dental Procedures COPD • Patients with COPD have an increased risk of post-op/procedure pulmonary complications depending on severity • Treat patients who do not have optimal reduction of symptoms (cough, SOB) and optimal exercise capacity before surgery • Combinations of bronchodilators, physical therapy, smoking cessation, antibiotics for exacerbations, and corticosteroids will reduce the risk.

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