The risks of any procedure can be increased by the

1. Health status o the patient

2. Complexity and duration of the case

3. Degree of invasiveness

4. Experience and skill of the operator

5. Addition of sedation or general anaesthesia

Risk StatusDefinitionApproach

INo overt systemic condition/sRoutine office care

May require sedation

IIMild /Moderate systemic diseases

Medically stableRoutine office care

Approach minor modification

IIISevere systemic condition/s

Medically fragile

Limited activity

Not debilitating

Emergency care

Medical consult

Modification

IVDebilitating systemic conditions

Constant threat to life

Emergency care

Medical consult

Care in hospital environment

VMorbid patientMaintain basic life support

Not expected to live

Status Classification for Dental Patients

American Society of Anesthesiologist (ASA)

Classification of Dental Treatment

Evaluation of Risk in Systemic Disease

Patient

Cardiovascular Diseases

Hypertension Angina Pectoris

Myocardial InfarctionInfective Endocarditis

Congestive Heart failure Previous Cardiac Bypass.

Previous Cerebrovascular AccidentPresence of Cardiac Peace Makers

Presence of prosthetic valve

Risk factors for cardiovascular disease

Smoking Excess alcohol Diabetes mellitus Hypercholesterolemia Lifestyle Obesity

It is important to assess Degree of compensation that the

patient has managed to achieve (signs and symptoms)

The efficacy of medication

The key issues for heart patient are pain control and stress management

Remember :

Hypertension

No underlying UnderlyingPathological C. Pathological C.

95%Normal Blood pressure is 120/80 mm Hg

Dentist should have a baseline level

Hypertension

Primary SecondaryDental Tx for controlled hypertensive patient is safe except

patient with stages III - IV

Periodontal Management in Hypertensive Patient

Elective dental surgery on post-MI patient

Myocardial Infarction (MI)

Old Reports:

A 6 month waiting period for cardiac stabilityRecently: Pt. ( medically determined ) isn't at risk

Surgery as early as 6 weeks after the event, with protocol

Stressful situation may cause additional raise in BP (Stroke, MI)

Post –operative bleeding Interactions between patient`s

antihypertensive medication and other medications.

Complications in Hypertensive Patients

Consultation with the physician Patient assessment (risk factors)

Emergency kit (Nitrate & Oxygen))

Achievement of profound anesthesia Stress reduction measures (iv.

Sedation) Preoperative pain medication Vital sign monitoring (blood pressure,

heart rate)

Presence of Cardiac Peace MakersAvoid using ultrasonic and sonic instruments.

Presence of prosthetic valves or valve diseases:

Antibiotic prophylaxis is important before dental procedure.

Endocrine Disorders

Diabetes Mellitus Thyroid Disorders Adrenal Gland Disorders Pregnancy

Abnormality of the circulating level of thyroxine due to overproduction (hyperthyroidism) or under production (hypothyroidism)

Parathyroid hormones regulate the level of calcium in the plasma by acting on the kidney, gut and bone.

Hyperthyroidism may lead to loss of lamina dura around the teeth.

Thyroid disease may present as a goiter. Thyroid function should be stabilized before dental treatment.

PTH,

It is hypercalcemic, removing the calcium ions from bone and transferring them to circulating blood.

It increases the urinary elimination of phosphates by reducing their tubular reabsorption.

It contributes to maintaining an optimal calcemia by intervening in the kidney’s physiologic tubular reabsorption of calcium.

It plays an important role in the intestinal absorption of calcium in synergy with vitamin D

Adrenal Insufficiency

Acute adrenal insufficiency is associated with significant

morbidity and mortality owing to peripheral vascular

collapse and cardiac arrest. Therefore the operator should be aware of the clinical manifestations and ways of preventing acute adrenal insufficiency in patients with histories of primary adrenal insufficiency (Addison's disease) or secondary adrenal insufficiency (most often caused by use of exogenous glucocorticosteroids).

Management of the patient in an acute adrenal insufficiency crisis1. Terminate treatment.2. Summon medical assistance.3. Give oxygen.4. Monitor vital signs.5. Place the patient in a supine position.6. Administer 100 mg of hydrocortisone

sodium succinate (Solu-Cortef) intravenously for 30 seconds or intramuscularly.

Prolonged use of corticosteroids

Bone fragilityRenal deficiencyMetabolic disorders (blood sugar

metabolism)Water retentionInhibition bone resorption

Prolonged use of corticosteroids

Determine …. Reason for treatment Patient’s response

Steroids act in three different ways that affect periodontal surgery;

1. They decrease inflammation and are useful in decreasing swelling and related pain.

2. They decrease protein synthesis and therefor delay healing.

3. They decrease leukocytosis and therefor reduce patient’s ability to fight infection

Whenever steroids are prescribed to patients for surgery, antibiotics should also be given.

Systemic complications of Diabetes Mellitus

Microvascular disease

Alteration in structure Cardiovascular disease

Thickening of vascular wall

Arteriosclerosis Stroke Nephrology Neuropathy Retinopathy

Diabetes-Induced Changes in Bone Formation

Inhibition of collagen matrix formation Alterations in protein synthesis Increased time for mineralization of osteoid Reduced bone turn over Decreased number of osteoblasts and

osteoclasts Altered bone metabolism Reduction in osteocalcin production

Surgical implant osteotomy

Blood clot formation

Bone resorption phase

Matrix formation phase

Bone deposition/ osteoid mineralization

Maintenance of osseointegration

Changes in wound healing proteins

Decreased number of osteoclast

Inhibition of collagen formation

Decreased number of osteoblast

Mineralization proteins reducedReduced bone turnover

Alterations in bone homeostasis

Change in diabetic status

Possible Risk Factors for the Diabetic Patient in periodontics Type of onset Age of patient Elevated blood glucose levels Regimen of glycemic control History of tooth loss due to periodontitis Poor insufficient wound healing history Extent of edentulous Smoking as a cofactor for implant failure

Hematological Disorders

Erythrocytic Disorders Polycythemia

(splenic enlargement, hemorrahges , thrombosis of peripheral veins).

Anemia

Leukocyte Disorders

Leukemia Platelet & Coagulation Anomalies

Problems with red blood cellsAnemia

Reduction in the oxygen-carrying capacity of the blood and is defined by a low value for hemoglobine

< 13.5 g/dl for men

< 11.5 g/dl for women

Severe Anemia

Hb < 7.0 g/dl

Poor Wound Healing

Thrombocytopenia

Seriously affect blood clotting.Sever hematoma

Bleeding disorders may be classified as

Coagulation disorders(hemophiliac A and B and von Willebrand's disease)

Thrombocytopenia (Platelet Disorders)(Thrombocytopenia is defined as a platelet count <100,000/mm 3 ).

Vascular Disorders

Laboratory Tests

Bleeding & Clotting T.

Hemoglobin Platelet Count Prothrombin Time

Partial thromboplastin time

Not sufficiently sensitive to be used as screening test.

Degree of anemia Platelet deficiency Plasma prothrombin level;

liver disease; defect in coagulation factor

Defect in coagulation factors Defects in capillary wall.

Normal bleeding time 2.5 – 8.0 minutesSevere bleeding more than 15 minutes Prothrombin time PT 11-14 seconds Partial thromboplastin time (PTT) 2.5-3.6

second

Normal Platelet Count 250.000 ± 100.000 cells/mm3

Spontaneous Bleeding 80.000 to 60.000 cells/mm3

Gingival irritation Gingival Inflammation

Liver Diseases

Liver is the site of production for most of the clotting factors, excessive bleeding during or after periodontal treatment may occur in patients with severe liver disease.

Many drugs are metabolized in the liver; thus liver disease alters normal drug metabolism.

Treatment recommendations for patientswith liver disease include the following

1. Consultation with the physician concerning current stage of disease, risk for bleeding, potential drugs to be prescribed during treatment, and required alterations to periodontal therapy.

2. Screening for hepatitis B and C.

3. Check laboratory values for prothrombin time and partial thromboplastin time.

Bone is the main calcium reservoir of the body, and maintenance of a proper serum calcium level is essential for homeostasis.

Kidney Liver Gastrointestinal Parathyroid diseaseVitamin D deficiency

Mineral Equilibrium:

The most important calcium conserving organ in the body.

Kidney:

Patients with < 50% normal kidney function are at risk for surgery

Renal Dialysis Avoid drugs that are nephrotoxic or metabolized by

the kidney such as

Phenacetin, streptomycin, tetracycline Extraction of all questionable teeth Elimination all source of infection Good oral hygiene Prophylactic antibiotic coverage Provide treatment on the day after dialysis, when the

effects of heparinization have subsided.

Vitamin D is synthesized in the skin in response to ultraviolet light.

Vitamin D

Vitamin D is Vitamin D is hydroxylatedhydroxylated in the liver and in the liver and kidney to produce to active metabolite of kidney to produce to active metabolite of vitamin D, 1.25-dihydroxycholecalcifero vitamin D, 1.25-dihydroxycholecalcifero (1.25- DHCC), (1.25- DHCC),

Absorption of calcium from the small Absorption of calcium from the small intestine is accomplished by 1.25- DHCC.intestine is accomplished by 1.25- DHCC.

Vitamin D Deficiency

Osteomalacia

Contraindication for Dental Implant

Poor healing potential

Unmineralized osteoid with inadequate strength

Osteoporosis

A reduced weight per volume unite of bone, without a modified mineral to organic matrix ratio or any anomalies in either.

Osteoporosis

It is a negative balance of bone remodeling, resulting in reduction in the quantity of bone (number & diameter of trabecular bone) and a thinner cortex.

It occurs in postmenopausal women and elderly men, resulting in bone trabeculae that are scanty, thin, and without osteoclastic resorption.

Prosthetic Joint ReplacementThe main treatment consideration for

patients with prosthetic joint replacements relates to the potential need for antibiotic prophylaxis before dental therapy.

Antibiotic Prohylaxices

Patient CharacteristicsDrug Regimen

Patients not allergic to penicillinsCephalexin, cephradine, oramoxicillin: 2 g orally1 hour before dental procedure

Patients allergic to penicillinsClindamycin: 600 mg orally1 hour before dental procedure

Patients not allergic to penicillins but unable to take oral medication

Cefazolin 1 g or Ampicillin 2 g intramuscularly or intravenously 1 hour before dental procedure

Patients allergic to penicillins and unable to take oral medications

Clindamycin 600 mg intralivenously 1 hour before dental procedure (must be diluted and injected slowly)

Medications of Interest to periodontal surgery

Anticoagulant Medications Bisphosphonates Immunosuppressive Medications Rheumatoid Arthritis

Patients on Anti-Coagulant Drugs

Heparin Bishydroxycoumarin (Dicumarol) Warfarin sodium (Coumadin) Phenindione derivatives Cyclocumarol Ethyl biscoumacetate Aspirin

Warfarin

Warfarin is administrated orally Action up to 6 daysManagement of:

Atrial fibrillation ( as thromboembolic prophylaxis)

Deep vein thrombosis

Prevention of embolisation secondary to MI

After prosthetic heart valve replacement

The therapeutic efficacy is monitored using the International Normalized Ratio (INR)

INR =Patient's Prothrombin Time

Normal Prothrombin Time

Normal 1.0-1.3

During anticoagulant therapy, 2.5-3.0

Pt. with prosthetic heart valve 3.0-4.5

Test to Monitor Oral Anticoagulants

Aspirin

0,5 to 1 mg /kg antiplatelet effect 5 – 10 mg/kg antipyretic effect 30 mg/kg anti-inflammatory response

Bisphosphonates

Laboratory Risk Assessment

C-telopeptides (CTx) (fragments of collagen that are

released during bone remodeling and turnover)

Immunosuppressive Medicated

Immunosuppressed patients have impaired host defenses as a result of an underlying immunodeficiency or drug administration (primarily related to organ transplantation or cancer chemotherapy).

Glucocorticoids (Prednisone)

Antibodies

Cytostatics (chemotherapeutic agents)

Immunophilins (cyclosporine)

Immunosuppressed individuals are at greatly increased risk for infection, and even minor periodontal infections can become life threatening if immune suppression is severe.

Chemotherapy is often cytotoxic to bone marrow, destruction of platelets and red and white blood cells results in thrombocytopenia, anemia, and leukopenia

Radiation Therapy

Most severe among the resulting oral complications

is osteoradionecrosis (ORN).

Decreased vascularity renders the bone less capable of resolving trauma or infection. Such events may cause severe destruction of bone. The risk of ORN continues for the remainder of the patient's life and does not decrease with time

Flap surgery or extraction of teeth after radiation may lead to ORN.

Hyperbaric oxygen therapy is frequently required for complete resolution.

Pregnancy

Second trimester is the safest time Do not perform long and stressful

procedures Short appt. Changing position from time to time

to avoid hypotension. Fully reclined position should be

avoided if possible.

No medication should be prescribed or radiographs taken unless the situation is emergency

Consultation with obstetrician.