management of the medically complex dental patient
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MANAGEMENT OF THE MEDICALLY COMPLEX DENTAL PATIENT
Brent Hutson, D. D. S., M. S.Director of Clinical ProsthodonticsBaylor College of Dentistry – Texas A&M University Health Science Center
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ASA Classifications ASA I—
Healthy patient free of organic disease ASA II—
Pt. With mild systemic Dz. That does not limit activity (smoking, obesity,controlled HTN)
ASA III— Pt with severe systemic Dz that limits
activity, but not incapacitated (past MI, CHF, COPD)
ASA IV— Pt with incapacitating Dz that is a constant
threat to life (acute MI, organ failure) ASA V—
Moribund pt not expected to survive 24 hrs with or without surgery
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Never treat a stranger…
Some exceptions Some reasons Risk vs. reward
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The Patient’s Chief Complaint
Should be recorded in the patient’s own words
Usually relates to one of the following categories Comfort (pain, sensitivity, swelling…) Function Social (taste/odor…) Appearance
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Medical/Dental HistoryExam and Interview Documentation of the current state of the
patient Documentation of where pathology
resides Facilitates the development of a
relationship Provides an opportunity for
undisclosed ‘problems’ to surface It’s the law
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Subtle Observations
Inactive or prior history of periodontal disease or issues…
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Diagnostic Process
Exam/interview Radiographs Diagnostic tests Pt. consent and approval
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The Consent Process…
Not just a form, but a process Originates from the legal community
Tort of battery Blanchard v. Kellum, 975 S.W.2d 522 (Te
nn. 1998).
Must be written (the law) but must also include discussion (Texas)
Affords an opportunity for communication and abatement of misunderstanding issues
Not fool proof, and no guarantees
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Barriers to H&P/Consent Process Lack of attention to detail Compartmentalization Production! Scheduling/Patient load Honest mistakes
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Take home message…
“Problems encountered during or after treatment can often be traced to errors and omissions during history taking and initial examination. An inexperienced clinician may plunge into the treatment phase before collecting sufficient diagnostic information that helps predict likely pitfalls.” Rosenstiel
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Now on to the good stuff!
Why are so many people taking so much medicine? Research and development Diagnostic thresholds Therapeutic criteria Marketing
Are there to many lifeguards on the gene pool? People are living longer People with historically terminal
illness
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AHA Prophylaxis Review
Dental Procedures in Which Endocarditis Prophylaxis Is Recommended for High Risk Patients: All dental procedures that involve
manipulation of gingival tissue or the Periapical region of teeth or perforation of the oral mucosa.*
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AHA Prophylaxis Review
*The following procedures and events do not need prophylaxis: Routine anesthetic injections through non-infected
tissue Dental radiographs Placement of removable prosthodontic or
orthodontic appliances Shedding of deciduous teeth Bleeding from trauma to the lips/oral mucosa
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What conditions warrant premedication?Yes… No…
Prosthetic valve PMH of IE PMH/Hx of congenital
heart disease Cardiac
transplantation
MVP PMH of Rheumatic
Fever Generic Murmur
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Prophylaxis Review Orthopedics
Not indicated for Patients with: Pins, plates and Screws
Decision Should be Based on Type of Dental Procedure
Patient’s Medical History Considered Generally- Medically Compromised with Total Joint
Medical Consultation is Always Advised
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Write narrative/questions here
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Corticosteroid Therapy
Long term vs. short term Oral, parenteral, topical
COPD/asthma, arthritis, oncology, some dermatological conditions
Some allergy conditions Inhaled and topical
Some dermatological conditions Allergies (respiratory, contact) Some short term pulmonary conditions
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Side Effects of Short-Term Corticosteroids
Sleep disturbance Increased appetite Weight gain Psychological effects, including
increased or decreased energy Rare but more worrisome side effects of
a short course corticosteroids include: mania, psychosis, heart failure, peptic ulceration, diabetes and aseptic necrosis of the hip.
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Side Effects of Long-Term Corticosteroid Therapy
Precipitation or aggravation of diabetes mellitus (high blood sugar).
Increase in circulating blood fat (triglycerides). Redistribution of body fat: moon face, buffalo hump and
truncal obesity. Salt/fluid retention: leg swelling, raised blood pressure,
weight increase and heart failure. Shakiness and tremor. Eye disease, particularly glaucoma (increased intraocular
pressure) and posterior subcapsular cataracts. Psychological effects including insomnia, mood changes,
increased energy, excitement, delirium or depression. Headaches and raised intracranial pressure. Increased susceptibility to infections, via immunosuppressant MAY NEED ADDITIONAL DOSAGE Peri-operatively
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Ultimate Outcome of Long Term Corticosteroid Therapy.
Cushing’s Syndrome Weight gain, particularly around
midsection/upper back Fatigue Muscle weakness Rounding face (moon face) Facial flushing Fatty pad or hump between your shoulders
(buffalo hump) Thin and fragile skin that bruises easily Slow healing of cuts, insect bites and infections Depression, anxiety and irritability Thicker or more visible body and facial hair
(hirsutism) High blood pressure
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Management of Patients with Liver Disease
Hepatitis A, B, C and Delta
Delta hepatitis occurs as a co-infection with acute hepatitis B/ or super-infection in carriers of hep- B, transmitted parenterally via blood/blood products
Type E- enteric transmitted similar to A Patients with active hepatitis Patients with positive
antibodies/subclinical
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Alcoholic Liver Disease
Fatty infiltrate; hepatocytes become engorged with fatty lobules
Alcoholic hepatitis; diffuse inflammatory condition characterized by destructive cellular changes
Cirrhosis; most serious form of alcoholic liver disease, is characterized by progressive fibrosis and abnormal regeneration of liver architecture in response to chronic injury
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Treatment of Patients with Alcoholic Liver Disease
The absence of ascites dental tx is usually well tolerated (including surgery)
Also look for fat deposits infraorbitally
Petechia, Rhinophyma, Parotid Hypertrophy and peripheral wasting
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Patients on “Blood Thinners” Aspirin
Aspirin and NSAIDs (non-steroidal anti-inflammatory
drugs):
Platelet Aggregation Inhibitors (Intrinsic)
Coumadin (Vitamin K) Extrinsic
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Aspirin/NSAIDs(non-steroidal anti-inflammatory drugs):
Aspirin's inhibits COX1 in the platelet involved in the formation of chemicals that increase a platelet's ability to cause platelet aggregation. It will inhibit the platelet for its lifespan 7-10 days.
Other NSAIDs (such as ibuprofen) inhibit platelet aggregation in the same way, but the effect is not as long lasting. At this time, aspirin has the longest anti-platelet action in this group of drugs.
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Platelet Aggregation Inhibitors -Aspirin
Patients taking aspirin usually tolerate procedures well (including extractions)
The clinician, as always, should evaluate the patients overall presentation
Look for petechiae Geriatrics
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Platelet Aggregation Inhibitors - Others
Dipyridamole (Persantine): Mechanism is unclear
Ticlopidine (Ticlid) and Clopidogrel (Plavix): Platelets require a molecule called ADP
to bind to the platelet in order to facilitate aggregation. Studies show that ticlopidine and clopidogrel inhibit the ability of ADP to bind to platelets
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Management of patients taking platelet aggregation inhibitors.
ASA, ASA in conjunction with another medication Generally ASA alone OK ASA plus another PAI; Stop meds x5 days The plavix burn
Consider a “platelet aggregation test” bleeding test
Also may consider PFT “platelet function test”
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Patients Taking Anticoagulants (coumadin/warfarin) PT/PTT
Prothrombin time (PT) and partial thromboplastin time (PTT) tests
Reagent Dependent INR
International Normalized Ratio Results from 1-1.5 (+/- 2.0) are
manageable Europeans treat up to 4 Use overlying measures (SURGICEL, Suture
and Pressure)
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Hemophilia/Genetic Bleeding Disorders Classic-severe hemophilia A/B will
likely have a history Mild/moderate and moderately
severe likely will not have a history Factor & AMICAR (aminocaproic acid)
von Willebrand’s Disease 3% of the population? described 1926 by Finnish physician Erik von
Willebrand arises from a qualitative or quantitative deficiency of
von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion
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Diabetes Mellitus
insulin-dependent diabetes mellitus (IDDM) Pt’s usually >40, usually have history severe, acute condition with a sudden onset of symptoms including: polydipsia, polyuria,
nocturia, polyphagia, loss of weight, loss of strength, marked irritability, recurrence of bed wetting, drowsiness, and malaise…
non-insulin-dependent diabetes mellitus (NIDDM). May or may not have history generally occurs after the age of 40 in obese individuals;
incidence increases with age Slow/sub-clinical onset, often controlled with diet/weight
control 1Olefsky JM: Diabetes mellitus. In Wyn~aarden JB, Smith LH, eds.
Cecil Textbook of Medicine, 17th ed. Philadelphia: WB Saunders; 1985.
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Management of the Diabetic Patient
Manifestations of diabetes Hyperglycemia Ketoacidosis Vascular wall
disease contribute to the
inability of uncontrolled diabetic patients to manage infections and heal wounds
Skin lesions Cataracts/ blindness Hypertension Chest pain Anemia Oral
candidiasis unexplained dry
mouth multiple caries periodontal disease
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Dental Management of Diabetic Patients
History/medical consultation prior to invasive tx. Verify medication as usual. Verify adequate intake of food. Schedule appointments in the morning
Time of high glucose and low-insulin activity Afternoon appointments are a time of low-glucose and high-
insulin activity which may predispose the patient to a hypoglycemic reaction.
Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of hypoglycemic reaction occurring.
A source of sugar, such as orange juice, must be available in the clinic should the symptoms of a hypoglycemic reaction occur.
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Surgical Considerations for the Diabetic Patient
It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained.
IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection.
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Lab Considerations
Blood sugar measurement, “D-stick” Hemoglobin A1C
The most widely used clinical test is measurement of glycated hemoglobin (also called A1C, hemoglobin A1C, glycohemoglobin, or HbA1c)
Although the A1C reflects mean blood glucose over the entire 120 day life span of the red blood cell, it correlates best with mean blood glucose over the previous 8 to 12 weeks.
studies have shown that there is a 10% decrease in micro- vascular risk for every 1 % reduction in A1c
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Pulmonary Disease
Chronic disease COPD Emphysema ASTHMA Inflammatory pulmonary disease
Acute disease Asthma Acute episode of chronic disease
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Dental Management of Asthmatic Patient Hx/Dx/Consultation Working/current inhaler present Avoid triggers/water spray/fumes Drug interactions:
ASA, NSAIDs, and narcotics
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Dental Management of COPD Patient Hx – look for co-morbidity No tx if acute presentation Treat in upright/semi-upright position Avoid rubber dam if not well tolerated
Narcotics > Pulmonary Depression Nitrous Oxide (controversial) Avoid Bilateral Mandibular or Palatal
Blocks Pulse oximeter is helpful, consider low flow oxygen Avoid sedatives other than benzodiazepines Drug interactions with COPD medication
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Patients with Cardiovascular Disease
Remember Local Anesthetics and Dosages
Treatment After Events Stints (Premedicate?)
Usually Cardiologist will advise to wait 6 weeks MI
6 mos. CABG (Cabbage)
3 mos. Coronary Artery Bypass Graft
Various Medications
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Risk Assessment
Cardiovascular disease Angina
Stable/unstable Congestive heart failure
Stable/unstable Hypertension
# of meds and level of control
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Cancer and Oncology Patients
Generally tolerate procedures and anesthetics well, prior to Oncology (Chemo/Radiation) phase of treatment
Medical Consultation Dental Treatment Should be ‘Phased’
Phase I- Hygienic/Caries Control Phase Phase II- Maintenance Phase Phase III- Restorative Phase
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Cancer and Oncology Patients (cont.)
Phase I (Hygienic Phase) Pre-Oncology
(Chemotherapy/Radiation) Aggressively Treat Periodontal Disease Remove Teeth with Questionable
Prognosis Fabricate trays for medicament
delivery Endpoint goal is patient that is free of
dental pathology
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Cancer and Oncology Patients (Cont.)
Phase II (Oncology Phase) Palliative and Supportive
Treatment Monitor Patient Closely Be Prepared to Alter/Modify Tx.
Plan Use of LED device to control
oral/pharyngeal mucositis
(KEPIV/ KEPIVANCE™) human keratinocyte growth factor
(KGF)
Use of ‘Magic Gargle’ or viscous lidocaine
Re-consultation with Oncologist is often required
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Cancer and Oncology Patients (Cont.)
Phase III- (Restorative Phase) Prognosis Should be Considered Progress from Stabilization Restorations to
Definitive Restorations
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Clinical Presentations Cancer/Oncology
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Clinical Presentations Cancer/Oncology
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Clinical Presentations Cancer/Oncology
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Psychiatric Patients
Medical Consultation/Communication
Copus Mentus/Competency Issues Medication Concerns
TCA’s, MAO’s, CNS Depressants Xerostomia
Root Caries, Candida…. Medico/Legal Concerns Focus of Psychosis
Case Report
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Psychiatric Patients (Clinical)
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Management of the patient on Oral Bisphosphonates
Oral and Intravenous Bisphosphonate-Induced Osteonecrosis of the Jaws. History, Etiology, Prevention, and Treatment Robert E. Marx, DDS
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Assessing the Dental Risk… Medical History
History, History, History Which medication taken? What was the dose and frequency? Was there concomitant use of prednisone
or other steroids?
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Clinical and Radiographic Examination… Panoramic and periapical films as
indicated Early signs of bisphosphonate toxicity
Generalized sclerosis of the alveolar bone and lamina dura
Widening of the periodontal membrane space
Clinical exam Tooth mobility unrelated to alveolar bone
loss
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Laboratory Testing…
CTX bone turnover marker C-terminal cross linking telopeptide Measurement of relative rate of bone
renewal Normal: 300-600 pg/ml Moderate risk of BONJ: 150-299 pg/ml High risk: <100 pg/ml
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Prevention of Oral Bisphosphonate Induced Osteonecrosis
Prevention—prior to initiation of agents oral status needs to be fully evaluated and treated
Drug holiday Use of alternative medications for
osteoporosis Raloxifene
Modulator of estrogen receptors rhPTH
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What to do with patients already on Oral Agents? Patients on agents for less than 3 years
with no comorbidities No alteration in treatment plan
Patients on agents less than 3 years with comorbidities With MD consultation: stop agent for three
months (+/- CTX testing) Continue drug holiday for three months
postoperatively Informed consent (in writing) very
important
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What to do with patients already on Oral Agents? For patients on agents greater than 3
years With MD consultation: discontinue agent
for 3 months preoperatively Continue drug holiday for 3 months
postoperatively CTX test
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What to do with an urgent need for surgery? When palliative measures are
insufficient, and a truly urgent situation arises (abscess, intensive pain) you are better off undergoing the procedure than to suffer the consequences of infection/pain persisting
Written informed consent
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Treating Oral Bisphosphonate Induced Osteonecrosis Usually less extensive than
parenteral agents With MD consult DC agent for 1 year
Antibiotics and chlorhexidine rinses Early debridement is contraindicated 60% of lesions the resorption-
sequestration process is complete within 6 months to 1 year
Remainder respond to less aggressive surgical debridement
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Orally Administered Bisphosphonates
Brand Name Manufacturer Generic Name
Actonel Procter & Gamble
Pharmaceuticals risedronate
Boniva Roche Laboratories ibandronate
Fosamax Merck & Co. alendronate
Fosamax Plus D
Merck & Co. alendronate
Skelid Sanofi Pharmaceuticals tiludronate
Didronel Procter & Gamble
Pharmaceuticals etidronate
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Intravenously Administered Bisphosphonates
Brand Name Manufacturer Generic Name
Aredia Novartis pamidronate
Zometa Novartis zolendronic acid
Bonefos Schering AG clodronate
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1 Week Post-Op
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6 Weeks Post-Op
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Oral Bisphosphonate ONJ Case
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Holistic/Environmentally Sensitive
Generally Two Categories Mis/Under-informed
Looking to Vitamins/Minerals/Herbs Poly-Symptomatic Patients
Diagnosis from ‘Alternative Medicine’
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Holistic/Environmentally Sensitive E.I. (Environmental Illness)
CS, EMS… American Academy of Environmental Medicine
Medical Consult Consult!!! Psychological/Psychiatric Component
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Holistic/Environmentally Sensitive
Appropriate Referral Often Alternative Medical Providers prefer
“Biological Dentist” Appropriate Referral Sequence
Best Time for This Referral is Prior to Treatment Referral After Treatment Raises Concerns
Abandonment Issues Liability for Treatment Rendered
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Holistic/Environmentally Sensitive
Excerpt from discussion board: My Brother, who was a patient at the clinic, is having a new bridge installed by
his dentist. Currently he has a temporary bridge held in with adhesive that he is strongly reacting too. Does anyone have any suggestions for less toxic dental products? Our dentist is very open to ideas on how to treat my brother so we are looking for sources and suggestions for less toxic materials. Thanks, JW He needs to go see a biological dentist and let them test him to see what he can
tolerate in his mouth. Then take results back to your dentist. It helped me.
When I come in contact with cable television, electronics, or fluorescent lights, copy machines, magnetic cards, I get a very strange feeling over my body, often tingling in my tongue. Can anyone identify with this strange feeling? I am very concerned about this condition. I have seen a neurologist, but no diagnosis.
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With this line of thinking….
Warning this water contains hydrogen which is known to be explosive!
Table salt contains chlorine – a known poison to humans…
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“Metal free” Practice
Is it really?
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Inorganic components of composite:
1. Quartz - SiO2
2. Borosilicate glass
3. Lithium aluminum silicate
4. Barium aluminum silicate
5. Strontium or zinc glass
And……..
6. Metal oxides – provide color
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Ha……..! Metals!
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Pregnant Patients
Medical Consult!! Defer Treatment Until 2nd/3rd Trimester Association Between Caries and Premature
Birth Phased (Hygienic Care) Usually Best Specific Medication Concerns
Tetracyclines in the pregnant and nursing ACE inhibitors
Angiotensin-Converting Enzyme Inhibitor Drugs Quinolones (Ciprofloxacin) *NB
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Parting shots...
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Effects of pregnancy, and organ failure on LA kinetics Renal failure: increases accumulation of metabolic by-
products
Hepatic failure: decreases clearance, increases half-life
Cardiac failure: decreases amide clearance
Pregnancy: increases amide clearance; decreases protein
binding
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ABSOLUTE CONTRAINDICATIONS TO LOCAL ANESTHESTIA…
Severe uncontrolled hypertension Refractory arrhythmia MI < 6 months ago Stroke < 6 months ago Unstable angina CABG < 3 months ago Uncontrolled CHF Uncontrolled hyperthyroidism