Lec 4: Medical Problems 1

Why is a medical history important?

o 1. To assess the FITNESS of the patient to undergo

treatment.

o 2. Enable to ID patients AT RISK and take measures to

REDUCE the CHANCES OF PROBLEMS arising.

o 3. Information needed to stratify (CLASSIFY) risk

o 4. Our procedure could adversely affect the medical

condition

o 5. Patients with medical conditions need to be

optimized prior to treatment (*controlled)

o 6. Certain conditions need to order investigations,

administer antibiotic prophylaxis prior to treatment

Decisions:
o You may not be able to completely eliminate the risk of
an adverse event Risk as much
o Goal is to reduce the risk as much as possible as possible.
Is remaining risk acceptable? Acceptable?
Is dental treatment going to provide overall Benefits?
benefit?

Hypertension
o The blood pressure (BP) will vary depending on????
AGE (*99
GENDER (*M/F)
ETHNICITY (*ASIAN, WHITE, BROWN etc)
ENVIRONMENT (*DEVELOPED vs DEVELOPING,
CLIMATE)
EMOTIONAL
ACTIVITY STATE
o BP== tends to INCREASE with AGE.
o Types of hypertension:
1. 1 Primary (Essential) hypertension
Unknown cause ???????????
Lifestyle and genetic predisposition
2. 2 Secondary hypertension
An identifiable cause is present
 Renal disease,
pregnancy,
endocrine etc.

KNOWWW!!!

o Pain/anxiety may lead to

acute elevation of blood pressure (BP)
Stress/anxiety reduction
Establishment of good rapport
o Concerns- bleeding, angina, MI, and stroke:
Has patient taken their medication today
Take BP on day
What is the normal range of BP
* with any kinda heart/bleeding/condition, did they
take their meds/what is their range, their BP????
o Management:
1. Short, late morning/early afternoon
appointments when endogenous circulation
catecholamines are low.
2. Adrenaline containing agents are not
contraindicated when proper injection
technique is adhered to. Aspirate, minimal
doses.
3. Patients on anti-hypertensives can suffer
from postural hypotension which may lead to
a transient loss of consciousness if raised rapidly
from a lying to sitting or standing position
Slow position changes!!!!
4. Consider the use of hemostatic measures if BP
is raised.

5. Avoid NSAIDs in patients taking ACE inhibitors:

they may cause a
deterioration in
renal function.
* above to read 6. BP >160/90 and 7. >180/110 or
>160/90

Ischaemic Heart Disease:

o Pathogenesis is inadequate coronary

perfusion or myocardial demand
o Heart is supplied by coronary arteries
o Narrowing common with age due to atherosclerosis
o Clinical Manifestation:
1. Angina pectoris
2. Myocardial infarction (MI)

1. Angina Pectoris:
Name given to episodes of chest pain
caused by myocardial ischaemia (*not
enough O2 to heart muscle)
Two main types exist: 1. Stable angina and
2. Unstable angina
o 1. Stable angina:
 Stable angina caused by
myocardial ischemia due to
narrowed coronary artery lumen
from atherosclerotic disease
Likely to occur at times of
increased myocardial oxygen
demand e.g. physical exertion.
Manage:
Glyceryl trinitrate (GTN)
often used as a vasodilator
(reduces venous return
and thus cardiac work)
(*venodilator!!)
o venous return
o cardiac work
Patients should have their
spray or tablets available
with them, and not
expired.
In some patients they may
need to use the spray
BEFORE treatment,
however it often results in
a headache, so patients
may be reluctant to use it.
Careful as it drops the BP,
patients must NOT GET
OUT OF THE CHAIR
QUICKLY!!!!
If the patient experiences
chest pain during dental
treatment:
o STOP treatment
o Give: GTN subling +
O2
o Keep sitting upright
o Monitor vital signs
o Should be relieved
2-3 mins then
rest!! &
accompanied
home
o >3mins no relief??
Summon med help!!

o 2. Unstable Angina
Chest pain experienced at rest
Often develops into MI
Management:
These patients should be
referred for medical
opinion, prior to any
dental treatment
 2. Myocardial Infarction (MI)- Heart
attack
Results from the
complete
occlusion of one
or more
coronary arteries
Patients within 6
months of an MI
are at greatest
risk of further MI,
chest pain or
arrhythmias or
other
complications
Elective treatment (*dental) should be
deferred for 3 months post MI, CABG, stent
placement
Minimize anxiety and pain
GP/Cardiologist may advise per-operative
use of GTN
Average length of effectiveness of coronary
artery bypass surgery 7.5-10 years
Consider medications of relevance to oral
surgery e.g., warfarin, aspirin,
clopidogrel
 Congestive Heart Disease.
o Most common causes are:
o *a chronic heart condition in which the heart
doesnt pump as well as it should. This leads
to backflow of fluid in the lungs due to
inefficiency .
IHD
Hypertension
COPD
o Patients have dyspnea
o May or may not have fluid in their lungs
o Patients do not tolerate lying flat and should be
placed with their head higher than their
heart.
o Avoid bupivacaine it is cardio-toxic
o Avoid NSAIDS

Rheumatic fever and Infective Endocarditis:

o Follows a sore throat caused by certain strains of Group
A B-haemolytic streptococci.
o Occasionally followed by chronic rheumatic carditis with
permanent cardiac valvular damage
o Unlikely to see patients with acute rheumatic fever
attack
o Certain types of dental procedures without antibiotic
cover will result in Infective Endocarditis in certain
patients suffering from rheumatic carditis
o * RF: affects mainly childhood (5-17 yos) is a
consequence of pharyngeal infection with GAB
hemolytic streptococci. Early deaths due to myocarditis.
Late sequelae include rheumatic heart disease, which
affects heart valves: mitral>aortic>> tricuspid. Early
lesion is mitral valve prolapse late lesion is mitral
stenosis.
ACUTE: throat infection with joint and skin issues
with fever and acute rheumatic carditis (5-7 days
after fever)
CHRONIC: 10-20 years valve deformity. No fever.
Ie mitral stenosis. ONLY heart. Vegetations grow
and can lead to thrombus.
o * IE:
Infection of the endocardial surface of the heart
and heart valves (mainly aortic or mitral valves)
Rare condition which can be fatal
Strep viridans main organism associated with
dental bacteraemia
Staph aureus main organism associated with
bacteraemia caused by IV lines,
immunocompromised in hospital patients.
o Patients at highest risk of IE:
 1. Prosthetic cardiac valve or prosthetic
material used for cardiac valve repair
2. Previous IE

3. Congenital heart Dz but only if it involves:

1. Unrepaired cyanotic defects, including
palliative shunts and conduits

2. Completely repaired defects with

prosthetic material or devices, whether
placed by surgery or catheter
intervention, during the first 6 months
after the procedure (after which the
prosthetic material is likely to have been
endotheliased)

3. Repaired defects with residual defects

at or adjacent to the site of a prosthetic
patch or device (which inhibit
endothelialisation)

4. Rheumatic heart disease in high-risk patients

5. NOTE: patients who have had a heart

transplant may also be at high risk of
adverse outcomes from endocarditis;
consult the patients cardiologist.

o Dental procedure prophylaxis:

o Dental procedure prophylaxis always required
Extraction
Periodontal procedures including surgery,
subgingival scaling and root planning
Replanting avulsed teeth
Other surgical procedures (e.g. implant
placement, apicectomy)
o Dental prophylaxis sometimes recommended:
Consider prophylaxis for the following procedures
if multiple procedures are being conducted, the
procedure is prolonged or periodontal disease is
present:
Full periodontal probing for patients with
periodontitis
Intraligamentary and intraosseous local
anaesthetic injection
Supragingival calculus removal/cleaning
Rubber dam placement (where risk of
damaging gingiva)
Restorative matrix band/strip placement
Endodontics beyond the apical foramen
Placement of orthodontic bands
Placement of interdental wedges
 Subgingival placement of retraction cords,

antibiotic fibres or antibiotic strips.

o Antibiotic prophylactic regimes

1) Amoxicillin 2g (50 mg/kg) taken orally 1 hr
pre-op Avoid penicillin if:
Hypersensitive to penicillin
Long term penicillin therapy
Has taken penicillin or a Beta-lactam
antibiotic more than once in the previous
month
2) Clindamycin 600 mg orally 1 hr pre-op

see:http://www.tg.org.au/etg_demo/desktop/tgc/ab
g/16602.htm
Atrial Fibrillation
o It is the COMMONEST rhythm disturbance
o Caused by chaotic electrical impulses in the atria, which
results in
Chaotic
Rapid
Uncoordinated
Weak
Contractions of the atria
o The chaotic signals bombard the AV node, usually
resulting in an irregular, rapid rhythm of the
ventricles
o Patient may have other medical conditions that is the
cause of the arrhythmia. Take good medical history and
assess BP
o Patients on medications that cause excessive bleeding
risk
1. Warfarin
2. Antiplatelets
Aspirin either mono or dual therapy with
Clopidogrel
If on dual therapy DO NOT extract. Refer to
oral surgeon.
3. NOAC.
o Avoid IO (intraosseous) and IL (intraligamentary)
injections to prevent excess systemic absorption .
o Patients maybe on a pacemaker
o Patients maybe on an automatic implantable cardiac
defibrillators (AICD)
May activate without warning causing the patient
to flinch, bite down which can result in injury to
both patient and clinician.

Cardiac Surgery, Prosthetic Heart Valves, Stents:

o Elective dental treatment should be AVOIDED for the 1st
3 months after cardiac surgery!!
o Atrial Fibrillation occurs frequently after MOST TYPES OF
cardiac surgery
o Patients on long term anticoagulant therapy:
Warfarin
Aspirin mono or dual therapy
Biological valves for first 3 months
Mechanical valves life long
o Endocarditis prophylaxis
o Lifespan of the prosthetic heart valves are limited