The first three lecture we will take about medically compromised patients and it's very important and

carriage you all make sure .

the reference of medically compromised patient is medical problem in dentistry , the doctor advise us to read from new edition .and there's another book temporary oral and maxillofacial surgery .

This lecture is called run through, we will go through the medical problems that we face as dentists in our clinics. As we always say we are doctors that treat patients with teeth but not doctors that treat teeth inside patients. any subject that the doctor run through it in this lec we should know them very extensively .

Any patients with medical disease we consider them compromised, but competent patients are patients who dont have any medical disease

In this lecture we will talk about cardiovascular diseases, respiratory diseases, and liver diseases, neurogenic diseases. So let's start with ischemic heart diseases ,what do we mean with ischemic heart diseases ? is the most common type of heart disease and cause of heart attacks. The disease is caused by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and reduces blood flow to the heart.

Ischemic heart diseases always the patient is coming with chest complain (chest pain ), when the patient tell you he\she has chest pain you should think about decrease in blood supply to myocardium . When the patient have ischemic heart disease he\she will have group of disease first of all Angina pectoris ,Myocardial infraction , Acute coronary insufficiency something u should about but it's not something u are require to know extensively . We will take very minimally about cardiac erythema, heart failure and sudden death in terms of cardiac arrest. Symptoms of cardiovascular disease in general : 1-Chest pain : The first and the main sign we need to be aware off , chest pain v.important . 2- Dyspnea (shortness of breath) : any patient with shortness of breath we should think about cardiovascular and ,respiratory problems . and the most cardiovascular disease that lead to dyspnea is left sided heart failure (in this disease the heart in left side doesnt work properly so the blood will accumulate in lung so no blood will go from lung to heart and this lead to dyspnea) 3- Cyanosis (bluish discoloration) : Is one of the main symptom of the (heart failure ) more than ischemic heart disease . it happens in asthma patients, and in cardiovascular diseases it happens

in any patients with less blood oxygenation to central nervous system, or it may be happen in children that they have right-to-left shunting or left-to-right shunting, these children have congenital heart disease, for example when the blood enter to right ventricular it will go to left ventricular due to ventricular defect and this lead to cyanosis 4-palpitations: it's happen when the patient has arrhythmia in general , like atrial fibrillation . when the patient feels irregular sort of palpitations in the heart it is called palpitation. Palpitation is part of dysrhythmia 5- Syncope: is sudden loss of consciousness due to decrease blood supply . 6-edema of the ankle :is one of the main sing of heart failure . we said that dyspnoea is happens due to left sided heart failure, but edema of ankle is happens is due to right sided heart failure (the blood from the body goes to right side of the heart but when the patient has right sided heart failure the blood will still in the body and doesnt go to right side of the heart and this lead to edema). *** dyspnea is happens due to left sided heart failure, but edema of ankle is happens is due to right sided heart failure***

Angina pectoris

Angina pectoris is ischemia to myocardial is temporary . we know that around the heart there are coronary vessel that supply myocardial if these coronary vessel for

any reason got block ,cause of hyperlipidemia and cause atheroma (atherosclerosis when there affecet the coronary artery so the blood supply to the heart will be decrease this will lead to Angina pectoris . Know what is relevant to us if patient have angina pectoris ,what should we do ? When you fill medical history and ask him/her if he/she feels chest pain when climbs the stairs , and the patient reply yes so this patient should be aware that they have some sort of ischemic heart disease and they describe that this happen in sort of frequent way (every week , 10 day , 1 month ..) then the patient has definite Angina pectoris regarding what we need to do with such patient without touch them ,we need to ask the patient to go to his physician . Regarding the appointment for such patient , patient with ischemic heart disease and angina pectoris we need to think about late morning this is because when patient get up in the morning, the epinephrine is peaking at early morning (the body is flushing with epinephrine), and in the night the epinephrine will be minimal, so we cant make the patients comes in early morning because the epinephrine is high and this increase the load on the heart and what we need is decrease the load not increase it , and also we cant make the patient comes in night because he/she will be tired , so the ideal timing is late morning so when we give L.A that contain epinephrine will not be as that as we give it in morning ,and it's debatable cause when we give LA generally we are not giving the LA intravascular , so in real dental practices it's make no difference . And we need to make sure to reduce anxiety and stress .

Some people claim that the local anesthesia contain epinephrine and this increase the load in the heart ,for such patients we can use local anesthesia without epinephrine but in case with angina pectoris and also MI you can use local anesthesia with epinephrine ,it most properly make nothing but you should take precaution not to give great number of cartilage. In cardiovascular compromised patient in general you shouldnt give more than 4 cartilages of local anesthesia with epinephrine (1:100,000) in case of adult Epinephrine for normal people up 0.2 ml which means around 7-8 cartilages but for patient with cardic compromised patent in general we should give up to 0.04 ml General anesthetic with patient with angina should be alright but if they have recent attach we should wait up 3 months . patient with angina pectoris he/she should have GTN (Glyceryl trinitrate) it dilate the vessel it has very sort of quick connection to the heart it easly dissorp from sublingal area up to blood stream and it cause vasodilation (lead to good blood supply to myocardial ) . In addition to use GTN sublingually (under tongue) to relieve angina, you should also give patient full oxygenation with mask. After doing this treatment and precaution you can continuo dental treatment after 5 minutes but if episode and pain of angina is still after 5 minutes so we will be afraid from MI.and such patient take aspirin the Q does aspirin interfere with our management ? No ,because they found when you stopping the aspirin for any dental procedure even the extraction compere the risk of stopping aspirin outway of benefit so when you read from the book

there some of doctors said you need to stop aspirn for 8 days (half-life of platelet 8 days ) if attached develop while you are doing something , what will you do ? first of all I will give him GTN and oxygen if it persist give them aspirin 300 mg chewable . we give morphine if it's persist , so if angina persist we should afraid of MI . so Aspirin , GTN , oxygen are the main medication that should stop that exude .

We have 4 types of angina pectoris: 1- Stable angina: it happens with effort, we ask the patient if he/she feels chest pain when he/she for example climbs the stairs, so if he /she feels pain then it is stable angina. Stable angina is less risky than unstable angina. 2-unstable angina: it can happen suddenly at rest.and it's happen in children The first two types happen mainly due to atherosclerosis, the patient has narrowing in coronary artery due to accumulation of atheroma (part of lipids) in intima of coronary artery. 3- Prinzmetal angina: it happens due to coronary artery spasm not atherosclerosis, it also happens (mainly in male) at rest like unstable angina but it differs from it in pathophysiology. 4-syndrome X: a lot of people feel sometimes chest pain, so he/she goes to the doctor and the doctor make for him/her examinations like exercise ECG (in this examination, they make the patients run in the special device and measure pulse

rate to see if the ECG differ from exercise to rest), catheterization, and all of these examinations repeal nothing. (From the book, syndrome x is clinical feature of angina but normal coronary arteries on angiogram (a functional abnormality of the coronary microcirculation)). Usually patients with angina pectoris when they make for them ECG, the ST segment will be depressed

Myocardial infarction

Myocardial infarction result from complete occlusion of one or more of coronary arteries (in angina atherosclerosis will block coronary arteries partly) that lead to complete deficient of blood supply to part of myocardium, so this patient will have crushing and strangling pain at mid sternal area that dont go away up to 5 minutes (the patient still have pain and may be have choking, and vomiting)

These patients need medical management, so if the episode of MI happens at dental clinic we will give the patient as angina GTN and oxygen in addition to aspirin (300mg) as anti-platelet (we ask the patient to chew aspirin not swallow it in order to reach blood stream quickly),also we give patient morphine (opioid) as pain killer because when reduce pain we will reduce also load on the heart ( when you feels pain if you measure pulse rate it will be high because CNS will stimulate heart to pump blood so you should decrease sensation of pain ). And the position of patient upright According to MI if patient come to dental clinic and says that he/she has MI from 6 months do you treat him/her or not? there is difference in opinion in this subject, some people says you shouldnt do any elective dental treatment if he/she has MI from 6 months , and some people says you shouldnt do any elective dental treatment if he/she has MI from 6 weeks MI patient will loss concussions , at first they will sweeting fatigue and after awile they wil loss concussions so you can put them supine , but in angina the patient is awake we put them in upright . So after 2-3 min if the chest pain is not relief we should call for help .

Congestive heart failure

It is inability of the heart to pump blood that need for metabolic process.These patients have part of heart cant pump blood for many reasons If the part of the heart that can't pump is on the right then the patient has right sided heart failure, and if in the left then he/she has left sided heart failure. If the patient has problem in heart and lung then he/she has cor pulmonale ,these patients have problems in heart and in pulmonary artery or in lung itself and this disease is the severest and most cardiovascular problems.

Patients with congestive heart failure in general, the most important thing you shouldnt lay them supine because if you put him/her in supine and the body of patient has liquid, it will go to the heart and what we need is to reduce the amount of liquid including blood that goes to the heart because the heart cant pump blood well so you shouldnt lay them supine

The second thing is that these patients take some medication like betablockers and digioxine that reduce pumping of the blood in order to reduce the load on the heart (instead pump from (60-1000) as normal person , it pump less that amount ), also these patients take medication that reduce pressure of the patient to reduce after load on the heart , so for example if you treat these patient and you put them in dental chair in position 60 degree and you raise the chair after doing treatment , it is possible in these patient to has hypotension . The appointment for these patients is late morning and also you should use less epinephrine. Another important thing, these patient take digoxin that is very important drug for them because it decrease heart pumping , but this drug is interact with many medication and one of these drug is antibiotics like erythromycin. We as dentists consider erythromycin second choice of the drug (amoxicillin is first choice) so this medication should be aware in this case .Also digoxin and some beta blockers like propranolol interact with epinephrine, now epinephrine alone raises blood pressure and beta blockers (antihypertensive drug) decrease blood pressure, but if two drugs interact it will lead to very big rise in blood pressure so for this reason you should decrease using epinephrine.

Hypertensive diseases Normal blood pressure is (120-130/80-89), we consider patient has hypertension if the blood pressure regularly (not after running or playing football because blood pressure already high after this activities) is above (140/90). These patients need special attention, and you need to know how bad is the hypertension (for example, if we ask the patient how hypertension with you, do you take medication for it? And the patient replies yes and say that he/she takes one medication in the beginning of disease then after two months he/she starts take two medication, then you know that this patient has bad hypertension). Dental management in hypertensive patients should be applied as other cardiovascular diseases, you should give 4 cartilage of local anesthesia not more, the amount of epinephrine in this 4 cartilage that should give is (.04) mg

According to GA, patients with hypertension you can give them GA. The drugs that use in GA are hypotensive agents. in the hypertensive patient who need treatment under GA that contain hypotensive agents and these patient also take tablets as antihypertensive, so doctors says if give them GA and in addition tablets as antihypertensive, it is possible to lower blood pressure a lot, but did this mean to make hypertensive patients to stop take antihypertensive medication before surgery that need GA? No you shouldnt stop it because the doctor says if these patients stop antihypertensive medication and take GA, after surgery these

patients has rebound hypertension, but in same time the management of such patients is a matter for the specialist anesthetists in hospital to control lowering of blood pressure. The main concern of hypertension patient to have an attack of hypertension , if hypertension exceed the limit the patient will have stroke . the myocardium in general can stand the hypertension in short period ,the brain can't stand it and there will be hemorrhage in the vessel . In general sedation in ischemic heart disease and hypertension is good . the main medication use as sedation is benzodiazepine (value ) . so when u give them the blood pressure will not be high . The treatment procedure should be short

Rheumatic fever

Rheumatic fever is caused by some sort of bacteria called Streptococcus pyogenes and this bacteria is type of beta-haemolytic streptococci How this disease happen? If person has sore throat(caused by streptococcus pyogenes) and doesnt take antibiotic for it , the body will produce antibodies to attack the bacteria but what

it happen is cross-antigenicity, that mean the antibodies will attack the bacteria and other part of the body as foreign agent and one of this part is heart. These patients come after while has multiarthralgia and then they have problems in heart. Not every person who had streptococcus pyogenes infection will have rheumatic fever, just who don't take treatment for sore throat will have permanent damage to the heart. In the past they said that patient with rheumatic fever should take prophylactic antibiotic (prescribe by dentist) to prevent infective endocarditis (IE) and other problems. So if patient comes to dental clinic and says that when he/she was child he/she has sore throat and dont take treatment for it so he/she develop rheumatic then you as a dentist should ask him/her do you take medication or refer to doctor ,if not then you should refer the patient to specialist doctor , then after referral you can give these patient prophylactic antibiotic and also some people say you can give these patient diazepam to reduce stress and also you should make dental appointment always short.

Infective endocarditis

IE is bacterial infection that leads to distortion of one of the cardiac valves, it caused by streptococci viridans that exist most commonly in oral cavity. The doctors found when examine patients with IE that their valves contain streptococci viridans, so they discover that this bacteria comes from oral cavity. So any patients have problems in cardiac valves in general should give them prophylactic antibiotic to prevent inflammation of valves.

How are dentists can lead to cause IE to the patients? The patient comes to bad dentist that dont ask about medical history, he/she just open patient mouth and do extraction to one of the teeth , then after two or three weeks, this patient go to the doctor because he/she has low grade fever and arthralgia ( pain in joint) then after that he/she starts has cardiac problems like dysrhythmias and pain in the heart so when he/she go to cardiologist and make examination, the doctor found that this patient has one of defective valve , how this happen? This patient had problem in one of valve like (mitral valve stenosis, prosthetic valve, pulmonary valve stenosis, rheumatic heart valve) so when the bacteria enter from oral cavity it will settle in that valve and lead to inflammation of valve and total distortion of that area, So these patient then should enter hospital and take antibiotics for 2 weeks , but some cases cant treat by antibiotic because infection lead to total damage of valve and these patients

need to prosthetic heart valve . Great percentage of patients will be died from IE, so it is disaster so these patients should take antibiotic

So if one of the patient come to the clinic and this patient is in high risk group like he/she has prosthetic heart valve and this patient need extraction of tooth then you should ask if he/she has allergy to penicillin if not then you can give him/her 4 tablets of amoxicillin (500) mg that mean when gathered all tablets it will 2g of amoxicillin or we can give ampicillin as liquid but amoxicillin is better. But if the patient is child we give 50mg/kg of amoxicillin or you can give liquid if child can't take tablet, and we make the patient return after hour to make sure that antibiotic in the blood is in the highest. Now if patient has penicillin allergy, you can give the patient clindamycin or we can give azithromycin (this drug is from macrolide antibiotic like erythromycin) or we can give cefazolin , and the same thing for children but we give less dose ( azithromycin 16mg/kg , clindamycin 20mg/kg)

Respiratory diseases The clinical feature that patients with respiratory disease have when come to clinic is cough, wheezing, cyanosis, finger clubbing (it is sign that you can see in

respiratory and liver and cardiovascular diseases, you should search a picture about it). The difference between sign and symptom: Sign: something that you as doctor see it. Symptom: something that patient tells you about it, the doctor can't see it. In general these patients with respiratory diseases( chronic and acute ) , you shouldnt give them GA , for example we have patient with influenza and this patient need surgery , the anaesthetist will tell you to postpone surgery until the patient recover from influenza , also in patient with asthma it is best to give GA to patient cautiously . The same thing is applied to analgesic (pain killer) and narcotic (drug that can't people exchange it like heroine and morphine), these drug lead to respiratory depression.

Asthma Asthma is happen due to bronchospasm and hyper-irritability, these patients will have expiratory wheezing (inspiration is active and expiration is passive) and also oxygen saturation (the amount of oxygen in blood) will be less (instead 95% it will be 90% for example) and also they have difficult in the breathing. These patients with asthma happen due to 2 reasons:

1-extrnisic factor: asthma may happen in spring because the patient smell specific thing that forms IgE in the body and this IgE will stimulate mast cell to release histamine. 2-intrnisic factor: in this patient the mast cell is unstable, so for any reason mast cell may be degranulated and release histamine so lead to asthma. In general these patients take spray and this spray is of two kind of inhaler: 1- Corticosteroid like cortisone 2-beta-agonisits like salbutamol Also these patients may take tablet of corticosteroid or another drug called fenoterol. Fenoterol is very good medication for asthma but the main problem in this drug that it make very bad drug-drug interaction.

Now come to dental management, these patients with asthma should refer if they need to medical consultation, always put medical consultation as first choice, and dont think that you can treat any disease alone. Also you should take aware to stress and anxiety because it is one of precipitating factor to asthma. Asthma can happen from dust (extrinsic factor), but one of main intrinsic factor that lead to asthma is stress and anxiety, so you should lower it as can as possible.

Local anesthesia can be provoking factor to asthma, so we should give them not as cardiovascular 4 cartidge but you should make sure not to give them more than need. In general anesthesia , the anesthesia when patients have asthma the will be conscious because the bronchiole will be spasm , so they put tube itself to give GA and these patients can easily go through infection like lung infection, pneumonia , so these patient under GA should be treated very cautiously . We should also know that the medication of the patients is safe, and you should make sure before doing treatment that this patient has the medication in hand (bronchodilator ). If the patient develops asthma attack what shall we do? 1-first you should ask the patient to take (4-6) push from the inhaler 2-we give oxygen, so oxygen is mandatory for any medical emergency 3- We give cortisone because asthma is sort of hypersensitivity. Finally doctor emphasizes us to have medical problems book and read cardiovascular and respiratory disease from it.

Box 5.11 patients at highest risk from infective endocarditis - prosthetic valves -previous infective endocarditis

-complex cyanotic congenital heart disease - surgically constructed systemic-pulmonary shunts or conduits - mitral valve prolapse with regurgitation or thickened leaflet

Sorry for any mistake Done by : Areej Al-halawani