high risk patients in

8/2/2019 High Risk Patients In

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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 *

high risk patients in

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