Transcript If a particular patient requires a series of dental treatments that

Any antibiotics that are prescribed should always be taken as directed. Failure to
do so can lead to the development of bacterial resistance to the antibiotic. If
have any problems associated with taking antibiotics (including the
development of a generalized rash or itching) should report immediately
Principles of prophylactic antibiotic use are:
Rick of infection must be significant.
Correct narrow spectrum antibiotic must be chosen.
Antibiotic level must be high.
Antibiotic must be in the target tissue before extraction.
Use the shortest effective antibiotic exposure.
Metastatic infection: is an infection that occurs at a location physically
separate from the portal of entry of the bacteria.
The classic and most widely understood example is bacterial
endocarditis, which may arise from bacteria are introduced into the
circulation as a result of tooth extraction. The incidence of
metastatic infection can be reduced if antibiotic administration is
used to eliminate the bacteria before they can establish an infection
at the remote site.
Factors necessary for metastatic infection:
Distant susceptible site.
Haemotogenous bacterial seeding.
Impaired local defenses.
Some impairment of the local host defenses.
Prophylaxis against infectious endocarditis
The rational for antibiotic prophylaxis of infectious endocarditis after
extraction has been based on that bacteremia has been shown to
cause infectious endocarditis; viridans-group streptococci are part
of normal oral flora and have been commonly found in infectious
endocarditis; extraction can cause bacteremia because of
streptococcus viridans which is generally susceptible to the
antibiotic recommended for prophylaxis of infectious endocarditis,
when the morbidity and mortality of infectious endocarditis are high
the patient must treated in the hospital with high doses of (IV)
antibiotics for prolonged periods. Although initial recovery from
bacterial endocarditis approaches 100%, recurrent episodes reduce
the 5-year survival rate of patients with this disease to
approximately 60%.
highest risk of endocarditis including:
Prosthetic cardiac valve.
Previous infectious endocarditis.
Congenital heart disease
Unrepaired cyanotic congenital heart disease, including
palliative shunt.
Completely repaired congenital heart defect with prosthetic
material or device during the 1st 6 months after procedure.
Repaired congenital heart disease with residual defects at the
site or adjacent to the site of a prosthetic patch or device.
Cardiac transplantation recipient who have cardiac valculopathy
Situation
Agent
Oral
Amoxicillin
Parentera
Ampicillin
l
Cefazolin/ceftriaxone
Regimen (30-60) min
before procedure
Adults
Children
2g
2g IM or
IV
1 g IM or
IV
50 mg/kg
50 mg/kg
IM or IV
50 mg/kg
IM or IV
Situation
Agent
PCN
allergy,
oral
Cephalexin
Clindamycin
Azithromcin/
clarithromycin
Cefazolin/ceftriaxone
Clindamycin
PCN
allergy,
Parentera
l
Regimen (30-60) min
before procedure
Adults
Children
2g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
1 g IM or
IV
600 mg
IM or IV
50 mg/kg
IM or IV
20 mg/kg
IM or IV
Some patients at risk for bacterial endocarditis may be taking daily doses
of penicillin to prevent recurrence of rheumatic fever or may already be
taking an antibiotic for other reasons. In these patients, the streptococci
may be relatively resistant to penicillin. The recommendation for this
situation must be use Clindamycin, azithromycin or clarithromycin for
endocarditis prophylaxis. The cephalosporins should be avoided
because of possible cross-resistance with penicillins.
If a particular patient requires a series of dental treatments that requires
antibiotic prophylaxis, a period of 10 or more days between
appointments is appropriate due to the administration of antibiotic for
several days or more continuously may promote colonization of the
patient by bacteria that are resistant to the antibiotic being given, thus
making prophylaxis more likely to fail. The 10-or-more day antibiotic free
period may allow antibiotic-sensitive organisms to repopulate the oral
flora. The baseline antibiotic resistance levels are not reestablished for
several months after a course of antibiotic. For this reason, the number
of dental visits should also be minimized, consistent with the patient's
tolerance level.
If the patient do not tell abut his endocarditis before the beginning of extraction,
so appropriate antibiotic prophylaxis should be administered as soon as
possible but definitely within 2 hours after the extraction to be benefit.
Patient at risk for infectious endocarditis have a comprehensive
prophylaxis program that includes excellent oral hygiene with
excellent periodic professional care by rinsed the mouth preextraction with an antibacterial agent, such as cholehexidine to
reduce the magnitude of bacteremias.
Coronary artery bypass grafting may consultation with the patient's
cardiologist to confirm the management.
Patients with a transvenous pacemaker have a battery pack
implanted in their chest with a thin wire that run through the superior
vena cava into the right side of the heart may consultation with the
patient's cardiologist to confirm the management.
Coronary artery angioplasty with or without stent placement may
consultation with the patient's cardiologist to confirm the management.
Patient receiving renal dialysis frequently have an arteriovenous shunt
surgically constructed in their forearms to provide the team ready
access to the bloodstream, may consultation with the patient's
nephrologist or renal dialysis team to confirm the management.
Patients who have hydrocephaly may have decompression with
ventriculoatrial shunt which induce valvular dysfunction, antibiotic
prophylaxis may required, may consultation with the patient's
neurosurgeon to confirm the management.
Patient who have had severe atherosclerotic vascular disease and
have had alloplastic vascular grafts placed to replace portions of their
arteries need prophylactic antibiotic if drainage of abscesses.
Prosthetic joint placed within 2 years.
Rheumatoid arthritis.
Systemic lupus erythematosus.
Insulin-dependent diabetes.
Previous prosthetic joint infection.
Congenital or acquired immunosuppressive diseases.
Malnourishment.
Haemophilia.
Asthma: when a patient relates a history of asthma, the dentist should 1st
determine through further questioning whether the patient truly has
asthma or has a respiratory problem such as allergic rhinitis. Patient
with asthma should be asked abut precipitating factors, frequency, and
severity of attacks, medication used, and response to medications.
Defer dental treatment until asthma is well controlled and patient has
no signs of a respiratory tract infection.
Listen to chest with stethoscope to detect wheezing before major oral
surgical procedures or sedation.
Use an anxiety-reduction protocol, including nitrous oxide, but avoid
use of respiratory depressants.
Consult patient's physician.
if patient is or has been chronically taking corticosteroids, provide
prophylaxis for adrenal insufficiency.
keep a bronchodilator containing inhaler accessible.
Avoid used of nonsteroidal anti-inflammatory drugs in susceptible
patients.
Chronic obstructive pulmonary disease: It is usually caused by long
term exposure to pulmonary irritants, such as tobacco smoke.
Defer treatment until lung function has improved and treatment is
possible.
Listen to chest bilaterally with stethoscope to determine adequacy of
breath sounds.
Use an anxiety-reduction protocol, including nitrous oxide, but avoid
use of respiratory depressants.
Consult patient's physician before administrating oxygen.
if patient is or has been chronically taking corticosteroids, provide
prophylaxis for adrenal insufficiency.
Avoid supine position.
keep a bronchodilator containing inhaler accessible.
Closely monitor respiratory and heart rates.
Schedule afternoon appointments to allow for clearing of secretion.
Renal failure: patient in renal failure require periodic renal dialysis.
These patient need special consideration during oral surgical care.
Chronic dialysis treatment typically requires the presence of an
arteriovenous shunt, which allows easy vascular access and heparin
administration, allowing blood to move through the dialysis
equipment without clotting.
Elective oral surgery is best undertaken the day after a dialysis treatment
has been performed. This allows the heparin used during dialysis to
disappear and the patient to be in the best physiologic status with
respect to intravascular volume and metabolic by-products.
Avoid the use of drugs that depend on renal metabolism or
excretion. Modify the dose if such drugs are necessary.
Avoid use of nephrotoxic drugs, such as nonsteroidal antiinflammatory drugs.
Defer dental care until day after dialysis has been given.
Consult patient's physician concerning prophylactic antibiotic.
Monitor blood pressure and heart rate.
Look for signs of secondary hyperparathyroidism.
Consider hepatitis B screening before extraction. Take hepatitis
precautions if unable to screen for hepatitis.
Renal and other organs transplant: The patient requiring surgery after
transplantation is usually receiving a variety of drugs to preserve the
function of the transplant tissue such as corticosteroids and may
need supplemental corticosteroids in the perioperative period,
immunosuppressive drug as cyclosporine A after organ
transplantation, may cause gingival hyperplasia. The dentist
performing oral surgery should recognize this so as not wrongly
attribute to hygiene problems.
defer treatment until primary care physician or transplant surgeon
clears patient for dental care.
Avoid use of nephrotoxic drugs.
Consider use of supplemental corticosteroids.
Monitor blood pressure.
Consider hepatitis B screening before extraction. Take hepatitis
precautions if unable to screen for hepatitis.
watch for presence of cyclosporine A.
consider prophylactic use of antibiotic, particularly for patients taking
immunosuppressive agents.
Hypertension:
Chronically elevated blood pressure for which the cause is unknown is
called essential hypertension. Mild or moderate hypertension
(systolic pressure of less than 200 mm Hg or diastolic pressure of
less than 110 mm Hg) is usually not a problem in oral surgical care.
Management of hypertension patient
Mild to moderate hypertension:
Recommend that the patient seek the primary care physicians'
guidance for medial therapy of hypertension.
Monitor blood pressure at each visit.
Use an anxiety-reduction protocol.
Avoid use local anaesthesia with adrenaline vasoconstrictor agent
but use plane anaesthesia or with fleprisin vasoconstrictor agent.
Avoid rapid posture changes in patients taking drugs that cause
vasodilation.
Sever hypertension:
Defer elective dental treatment until hypertension is better controlled.
Consider referral to an oral and maxillofacial surgeon for emergency
problems.
Hepatic disorders
The patient with sever liver damage requires special consideration
before oral surgery is performed. An alteration of dose or avoidance
of drugs that require hepatic metabolism may necessary. The
production of vitamin K-dependent coagulation factors (II, VII, IX, X)
may depressed in sever liver diseases. Portal hypertension caused
by liver disease may also cause hypersplenism, a sequestering of
platelets causing thrombocytopenia and causing prolonged bleeding
time. Patients with sever liver dysfunction may require hospitalization
for dental surgery because their decreased ability to metabolize the
nitrogen in swallowed blood may cause encephalopathy.
Attempt to learn the cause of liver problem; if the cause is hepatitis
B, take usual precautions.
Avoid drugs requiring hepatic metabolism or excretion; if their use is
necessary, modify the dose.
Screen patients for bleeding time with platelet count, prothrombin
time, partial thromboplastint time.
Attempt to avoid situations in which the patient might swallow large
amounts of blood.
Diabetes mellitus: It is caused by an underproduction of insulin, a
resistance of insulin receptors in end-organs to the effect of
insulin or both. Diabetes is commonly divided into insulindependent or non-insulin-dependent diabetes.
Insulin-dependent diabetes usually begins during childhood or
adolescence. The major problem is an underproduction of
insulin, which results in the inability of the patient to use
glucose properly. The serum glucose level rises above the
normal level which lead to glucosuria, polyuria, and
polydepipsia.
Patients with non-insulin-dependent diabetes usually produce
insulin but in insufficient amounts because of decreased insulin
activity. Insulin receptor resistance, or both. This type begins in
adulthood, is exacerbated by obesity.
Insulin-dependent diabetes:
Defer surgery until diabetes is well controlled; consult physician.
Schedule an early morning appointment; avoid lengthy appointment.
Use an anxiety-reduction protocol, but avoid deep sedation technique
in outpatients.
Monitor pulse, respiration, and blood pressure before, during, and
after surgery.
Maintain verbal contact with patient during surgery.
Advise patients not to resume normal insulin doses until they are able
to return to usual level of caloric intake and activity.
Consult physician if any questions concerning modification of the
insulin regimen arise.
Watch for signs of hypoglycemia.
treat infections aggressively, and give antibiotic post extraction.
Non-insulin-dependent diabetes
Defer surgery until diabetes is well controlled; consult physician.
Schedule an early morning appointment; avoid lengthy appointment.
Use an anxiety-reduction protocol, but avoid deep sedation technique
in outpatients.
Monitor pulse, respiration, and blood pressure before, during, and
after surgery.
Maintain verbal contact with patient during surgery.
Consult physician if any questions concerning modification of the
insulin regimen arise.
Watch for signs of hypoglycemia.
treat infections aggressively, and give antibiotic post extraction.
Adrenal insufficiency: Diseases of the adrenal cortex may cause adrenal
insufficiency. The most common cause is chronic therapeutic
corticosteroid drugs.
Use an anxiety-reduction protocol.
Monitor pulse, respiration, and blood pressure before, during, and
after surgery.
Instruct patient to double usual daily dose on the day before, day of,
and day after surgery.
Hereditary coagulopathies: patients with inherited bleeding disorders
are usually aware of their problem, allowing the clinician to take the
necessary precautions before any surgical procedure. However, in
many patients, prolonged bleeding after the extraction of the tooth
may be the 1st evidence that a bleeding disorder exists. Therefore,
all patients should be questioned concerning coagulation after
previous injuries and surgery. A history of epistaxis, easy bruising,
hematuria, heavy menstrual bleeding, and spontaneous bleeding
should alert the dentist to possible need for a presurgical laboratory
coagulation screening. A PT is used to test the extrinsic pathway
factors (II, V, VII, and X)m whereas a partial thromboplastin time is
used to detect intrinsic pathway factors.
Platelet inadequacy and count usually cause easy bruising and is
evaluated by a bleeding time.
The management of patients with coagulopathies who require oral
surgery depends on the nature of the bleeding disorder. Specific
factor deficiencies such as hemophilia A, B, or C or von Willebrand's
disease are usually managed by the perioperative administration of
factor replacement and by the use of an antifibrinolytic agent such as
aminocaproic acid (Amicar). The physician decides the form in which
factor replacement is given, based on the degree of factor deficiency
and on the patient's history of factor replacement. Patients who
receive factor replacement sometimes contract hepatitis or human
immunodeficiency virus. Therefore, appropriate staff protection
measures should be taken during surgery.
Defer surgery until a hematologist is consulted about the patient's
management.
Obtain baseline coagulation tests as indicated (prothrombin time,
partial thromboplastin time, bleeding time, platelet count) and a
hepatitis screen.
Schedule the patient in a manner that allows surgery soon after any
coagulation-correcting measures have been taken (after platelet
transfusion, factor replacement, or aminocaproic acid administration).
Augment clotting during surgery with the use of topical coagulationpromoting substances, sutures, and well-placed pressure packs.
Monitor the wound for 2 hours to ensure that a good initial clot forms.
Instruct the patient in ways to prevent dislodgment of the clot and in
whet to do should bleeding restart.
Avoid prescribing nonsteriodal antiinflammatory drugs.
Take hepatitis precautions during surgery.
Radiotherapy problems
The time allowed after extraction before beginning radiotherapy
traditionally, 7-14 days or delayed for 3 weeks.
osteoradionecrosis (ORN) has been defined as the exposed irradiated
bone that fails to heal over a period of 3 months.
Predisposing factors for ORN include:
anatomic location of the tumour.
total radiation dose.
mode of radiation delivery.
dental status.
Recommendations have been made in surgical practice in an attempt to
reduce the risk of developing ORN. These can be broadly classified
into:
preventative oral care
adjuvant therapies such as use of hyperbaric oxygen before and after
tooth extraction
modified surgical techniques
a combination of pre- and post-operative antimicrobial protocols.
HBO therapy is the administration of oxygen under pressure to the
patient. HBO has been shown to increase the local tissue
oxygenation and vascular ingrowth into the hypoxic tissues.
The usual protocol fro such treatments is to have between 20 and 30
HBO dives before extraction and 10 more dives immediately. The
patient usually undergoes one HBO session each day. Therefore, it
takes 4-6 weeks to get 20-30 treatments before surgery, and 2 weeks
of treatment after surgery.