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*HIGH RISK PATIENTS IN
ORAL SURDERY*P. With angina pectoris :
Angina pectoris is obstruction of the arterial supply to the
myocardium .
Cause by arteriosclerosis of the coronary artery .
Occurs in Men over age 40 .
Symptoms :
Heavy pressure or squeezing sensation in the patient's substernal region
that can radiate into the left shoulder and arm and mandible region
.Stimulation of vagal activity occur with :
- Nausea .
- Sweating .
- Bradycardia.
The attack occur by :
Exertion, anxiety or during digestion of large meal .
Diagnosis :
Depend on :
- - Clinical exam .
- - ECG - electrocardiogram .
Treatment :
- Nitroglycerin under the tongue .
- I . V valium .
- Dilatation drugs for blood vessel .
- Inderal 10-40mg /12h …et .
Dental treatment for patient with A.P.
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1- If the Angina pectoris arise only during exertion and respond to
nitroglycerin the oral surgery procedure are safe when performed with
proper precautions .
2- Uncontrolled angina pectoris surgery should be delay until a medical
consultation is obtained .
3- Local Anesthesia without adrenalin or nor-adrenalin .
4- The safe local anesthesia is lidocaine hydrochloride .
Cardiac Arrest :
- It means suddenly stop breathing and circulation .
Reasons : 1- Drugs :
Like analgesic , Anesthetic or hypersensitivity to drugs like antibiotic
{penicillin}.
2- Mechanically factors :
Like liquid aspiration or foreign body {tooth or anything else} .
3- Heart diseases and pulmonary diseases .
4- Pain {shock} .Diagnosis :
- Absence of chest movement .
- Absence of breathing .
- Absence of pulse .Management :
We must fast began the treatment to avoid the brain damage which
happen during 4-6 minute .
- Open the airway :
- Breathing mouth to mouth or synthetic respiration ,
- R emove the foreign body …
- Cardiac massage 4 massage to one breath {mouth to mouth} .
- I.V drips{liquid}.
- 5 ml adrenaline 1/10000 I .V or directly inject to heart .
- Atropine if pulse less than 60/ min .
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- For removing foreign body the patient lay down vertically .
Press manually on the chest .
-Follow up the breathing after the removing the F.B .
Hypertension :
We must count everyone who has 90/150 in rest situation after two time
taking measures on left and right hand .
Normal rate :
- Systolic 90 – 140 mm / mercury .
- Diastolic 60 – 90 mm / mercury .
Reasons :
- 90 % of cases are unknown .
- Renal causation .
- Heart causation .
- Drugs .
- Tumors .
Symptoms :
* Headache .* Ears buzzing .
* Vertigo .
* Bleeding from nose .
Dental treatment :
* Specialist – Medical consultation .
* We can do dental treatment for patient well controlled don't give him
adrenalin in local anesthetic solution it rise the blood pressure .
* If the pat, use antihypertension drugs the morning dose must
be taken .* Patient with several hypertension{systolic is 200or more and 110 or
more diastolic delay the surgical procedure until the pressure is better
controlled .
Hypotension :
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Systolic is less than 80 .
Clinically :
* Rush in pulse and breathing .
* Agitation .
* Nausea .
* Vomiting .
Reasons :
* Drugs using over does antihypertension .
* Loosing blood or liquids .
* Hypothyroidism .* Heart reasons infarction
Management :
* Patient lying back with elevate the legs up .
* Give O2 . If there is no effect .
* Open vein and give fluid{glucose}.
Bleeding Disorders :
- Un normal bleeding for different reasons .Can grouped into :
* Anemia .
* Leukocyte disorder .
* Coagulation factors abnormality .
Any bleeding disorder cause :
* Prolonged bleeding which can't be controlled by routine haemostatic .
* May cause several internal bleeding .
* Postoperative infection and delayed wound healing .
Management :
* Avoid deep trauma of the pat .
* Complete haemostatic must prepared .
* Trans fusion of blood or blood product if necessary.
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* Give vitamin B complex a vitamin C{they help to form blood cloth and
wound healing}.
* Give systemic coagulant like vitamin{k}orally 3-5days .
* Cover the patient by broad spectrum antibiotic .
The bleeding may be :
1- Spontaneous either subcutaneous or submucosa .
2- May be post surgical procedures .
Coagulation Mechanism :
It depends on :
1- Blood vessel .2- Blood platelet count .
3- Coagulation factor .
Classification is depend on :
1-Reasons :
- Immunity diseases in any part of body .
2- Blood vessel :
- Purpura .- Allergy .
- Alcoholisms .
- Infection .
3-Platelet count :
- The normal rate is 150-450 thousand / mm3.
Less count cause by :
Purpura : Drugs .
Chemical .
* Leukemia .
* Splenomegaly .
* Infection in the blood vessel .
4-Coagulation factors :
* Hemophilia {definition of factor VIII}.
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* Crismes disease {definition of factor IX}.
Hemophilia :
Definition :
It is a genetic diseases in men only .It has three types :
1- Hemophilia A insufficiency factorVIII .
2- Hemophilia B insuff.factorXI .
3- Hemophilia C insuff. factor XIII .
HemophiliaA :
It reasons is insufficiency of VIII coagulation factor it can be :
1- Grievous case :
The percent of factor VIII is 1-2 % .
It starts in childhood with spontaneously bleeding or after circumcision .
2- Moderate case :
The percent of factor VIII is 3-24 % bleeding is discontinuous happen for
example post simple extraction .
3- Soft case :
The percent of factor VIII is between 25-50 % .
Laboratory exam :
Coagulation time is prelate{more than 30 minute}.
Treatment :
No treatment recurs but you must intension about emergency case .
In general the bleeding treatment is :
* For topical trauma press locally for 5 minute .
* Press with swab cotton with adrenaline solution 5 minute .
* If blood not stop use trombine powder on the trauma.
* Stitch if the wound is wide only .
* Acrylic plate which we do before operation .
* Blood transfusion fresh blood or dry plasma .
- Vitamin K and C injection .
- Cold compress .
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- Tea bags{the tannic acid help to stop the bleeding} it use for the longer
time bleeding 2-3hours .
* The best way is to be given factor VIII before surgical procedures .
Stitch must be nonresorable .
Important Note :
Don't write these analgesic for patient with bleeding disorder :
* Aspirin .
* Indomethacine .
* Ketoprofine .
If you want to write analgesic you can write :* Paracetamol .
* Codeine .
Anemia :
Anemia with iron insufficient .
Bone marrow can`t product enough red blood cell because of iron is
important to form hemoglobin .
Causes :
* Menstruation-pregnancy or lactation
* Children one year old .
* Long term using aspirin .
* Trauma or gastritis .
Symptoms :
* Blanching , feel tired , nausea .* Tongue blanching , fissuring the angel of lip .
Lab .exam :
* Less red blood count and less H B % .
* Less iron .
Treatment :
* Iron sulphate 200 mg / 8 hour per mouth .
*Anemia B12 and folic acid insufficient the treatment is B12 and F.A.
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Important Note :
Don't write Aspirin like analgesic and chloramphenicol for
treatment of infection instead of it you can write paracetamol and
Ampicilin . Jaundice :
It is a yellow color for skin and eye's sclera as result of arising blood
bilirubin and it is a clinical view for hepatic diseases .
The normal rate of bilirubin is to 10 mg/L .
We discover jaundice when the eye's sclera and skin are yellow and
blood bilirubin is 20-30mg/ L .It is divided to :
Jaundice before liver :
The liver cell are healthy and the lesion in the hemolytic of blood .
Hepatic jaundice :
It cause by infection either A or B or non A,B infection .
Post hepatic jaundice :
It is congesting jaundice by stones , tumors or obstruction duct .Dental treat :
Jaun.patient has yellow mucous membrane and tendency for long
bleeding after any surgical procedure .
* The best is to delay extraction or another surgical procedure .
* Avoid infection trauma by needle .
* Use gloves and disposable needles .
* If necessary medical consultation .
Diabetes Mellitus :
It is divided to :
1- Diabetes insulin dependent or Juvenile diabetes .
2- Diabetes Non insulin dependent or adult diabetes.
Symptoms first one :
- Thirst .
- Polyuria .
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- Hunger .
- Less weight .
- Tendency to affected with infection .
Symptoms second :
1- Fatty . 2- pruritus . 3- Seeing disorder .
Disorders :
- Tendency to be affected with infection :
- Hypoglycemic coma .
- Diabetic coma .
- Heart diseases .- Gingivitis ,alveolititis , paradontosis .
- Sialoadnitis .
- Multiple caries .
- Delay the wound healing .
Diagnoses :
Depends on :
1- Fasting blood sugar more than 140 mg%{normal rate 80-100 mg%}.
2- Random blood sugar two hours after meal more than 200 mg % .
Treat :
* For the first one we give insulin .
* For the second diet control and anti diabetic drugs
Dental treat :
If the patient without complication you can do the dentaltreatment with :
* Fasting blood sugar to 120 mg % .
* Random lees than 200 mg % .
* Local anesthetic solution without adrenalin to avoid tissue necrosis and
hyperglycemia give vitamin B,C .for healing.
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* Patient insulin dependent let him take insulin and normal meal + lot
of sweets and to be treated in the morning .
* For big operations :
- Medical consultation and antibiotic .
Thyroid Diseases :
Divided to :
* Euthyroid .
* Hypothyroid .
* Hyperthyroid .
Euthyroid has no risk for any surgical procedure but in both hypo andhyper is best to postponed till the patient is euthyroid .
Hyperthyroidism :
-You can see it in adult women more than in men .
Symptoms :
* Exophthalmoses .
* Tachycardia .
* Less weight .
* Anxiety .
* Heart and vascular diseases .
Dental treat :
Every dentist may doubt that patient is affected if he has these
symptoms :
* Tachycardia .
* Without tolerance to hot .
* Arising pulse .
Treatment :
Before extraction
- Iode .
- Anti thyroid drugs.
- Thyroidectomy.
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So :
* Consultation .
* Avoid General anaesthetize for patient with thyrotoxicosis .
Adrenalin is Contraindicated . Thyroid storm :
It is emergency case in dental practice with :
* High heat – agitation – tachycardia .
* Coma .
Management :
* Less the heat .
* Hydrocortisone 100 – 300 mg .
* Inderal 40 mg / per mouth every 8y .
* Drugs of thyroid .
* Con . Medical sp .
Hypothyroidism :
- Adrenaline in local anesthetic solution has no effect.
- Avoid to use narcotic drug + barbiturate drugs .Respiratory Diseases :
The pat should be asked about asthma or chronic bronchitis .
If the pat is treated under L.A the bronchodilator inhaler should be kept
ready for use in emergency .
Renal Diseases :
Patient with renal failure , nephritic syndrome or chronic infection are
risk pat .
They may develop postoperative sepsis , secondary hypertension or
anemia .
Management :
* Consultation urologist must be done .
* Covered with broad spectrum antibiotic to prevent sepsis.
* Safe antibiotic are Amoxicillin or doxycyline .
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* Aspirin is contraindicated .
Pregnancy woman :
The main dental consideration are :
1- Minimize radiographic exposure .
2- Prevent supine hypotension .
3- Avoid hypoxia .
4- Withhold drugs that cross the placenta and damage to the fetus .
The stage of fetal development :
{first , second or third trimester} is very important for dental treatment .
* During the first the dentist give and prevent oral health care .Minimize the likelihood of miscarriage .
* Second is the safest time to provide dental care and extraction
* Third all routine care should be postponed until the delivery .
L . A for pregnancy woman :
* Administer intraoral local A .slowly better with aspiration .
* Avoid L . A with vasoconstrictor because epinephrine stimulate cardiac
activity and elevatesblood pressure .
Lactation :
L . A . S has effect on the milk of mother and the child feeding .
But if it is safety to use procaine,but you must advice mother to feed her
child before extraction and a new milk 2 hours after extraction.
Menstruation :
Don't extraction during first three days to avoid so much{Bleeding}.Prophylaxis for the prevention of infective endocarditis
Orally :
* Adult over 30 kg :No allergic to penicillin .
* Amoxicillin 3 g / hour before dental treatmentthen 1,5 g 6 hour after
the initial dose . adult over30 kg .
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Allergic to penicillin or has history of rheumatic fever erythromycin 8oo
mg 2hours before dental treatment followed by half original dose 6hours
after the initial dose .
Intra .V. or I .M .
Adult or children over 30kg no allergic 2g ampicilin 30 minutes before
treat and 1g ampicilin orally 6 hour after initial dose .
For allergic clindamycin 10mg / kg 30min before treat followed by half
original dose 6hours after the initial dose .
For high risk patient :
Non allergic Ampicilin 2g I . V combined with gentamycin 30 min beforetreat 1,5 g amoxicillin orally 6hours after
repeated 6hours after initial dose .
Allergic :
- Vancomyin 1g I.V slowly before treatment .
* Pat with congenital heart defect {unrepaired cong . heart defect}is as
above .
* For pat who repaired defect within the past 6 mon don't require
antibiotic coverage .
* Transmissible Viral Infection * Hepatitis : It is hepatic cell destruction by viral infection .
It has a number of kinds like A , B , C or D.
The most important for dental practice is hepatitis B .Hepatitis A :
- It is cause by A virus .
- It affect children .
- It is without jaundice .
- It is spread by mouth, water or stool .
- Anorexia :
it is the important symptom .
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- Palpation pain on the liver .
- Lumph hyperthrophy .
Treatment : - Earbohydrate , Vitamines . - Avoid suets .
- No special treat .
Hepatitis B: - It is important for dental practice . - It cause by B virus .
Spread by :
Blood transfusion . during extraction or any other surgical procedure .
Syrings using for more than one patient .
Narcotics drugs . or :
Sexually transmitted .
- Don't traumatize your fingers or hands .
- Wearing mask and looking glass .
- Always send the patient for primary health center for further
management . Dangerous factors are:
- Homosexual .
- Haemophilic .
- Hospital's work .Incubation period :
Is 1-6 months .
The virus is resistant for disinfection and can alive outside of
The body .
Symptoms :
- The main symptom is anorexia .
- Fever .
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- Joint pain .
- Patient feels tired . Lates :
- Jaundice continue for 1-4 weeks .
- Hepatomegaly .
Treatment :
Like the above .
Prophylaxe :
- Vaccination for all health workers .
It is by three injections :
- First one .
- Second after one month .
- The third is after 6 months .
Supporting does for protecting, is every five years .
Management or Notice :
- Treat every patient as he is effected .
- Dress gloves when working .
- Dress gloves .
- Use disposable instrument .
- Disinfected the chair and clinic after finishing .
The acquired immune deficiency syndrome AIDS - It may primary Transsimated from mother to child .
Secondary :
- It affect lymph cell B or T or both and decrease the cell-
Mediated imununity .
- It cause by HIVI .
- Transmitted by :
- Sex male homosexual activity heterosexual .
- I.V drugs .
- Blood transfusion .
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- Contaminated syringe .
- Narcotic patient .
Decrease immunity can cause this infections :
- Fungal infection oral candidosis .
- Viral infection hairy leukopluku , herpes .
- Bacterial infection gingivitis , paradontosis degenerative gin.
- Tumours kaposiesarcoma .
- Infection with unknown reason aphtosis , delay healing ,decrease
platelet cell count .
- Hyperthrophy salivary glands .Notice :
- Patient must be treated alone in clinic .
- Wearing gloves {D. and sister}.
- All instrument must be disinfected using only for this patient .
- Disposable needles and syringe must be used .
DOCTOR* AHMED SALEH ASSAEDY *