Periodontal Management Of Medically Compromised Patients Question And Answers

Periodontal Management Of Medically Compromised Patients Question And Answers

• In recent years there has been an increase in medically compromised patients seeking periodontal therapy. These patients may require modification in their treatment plan either as premedication, during the procedure, or during postoperative care.
• A detailed discussion on medically compromised patients is beyond the scope of this book. Only a few important conditions have been highlighted in this chapter.

Question 1. Describe the cardiovascular considerations in periodontal treatment.
Answer:

Infective Endocarditis Or Rheumatic Heart Disease

• Infective endocarditis is an infection of the endocardium or vascular endothelium. The disease may occasionally occur as a fulminating or acute infection.
• Those at risk of developing endocarditis should receive antibiotic therapy before undergoing a procedure likely to result in bacteremia.

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Prophylactic Regimens for Dental and Oral Procedures

• IM indicates intramuscularly, and IV, intravenously.
• Total children’s dose should not exceed the adult dose.
• †Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.
• All recommendations are made by the American Heart Association

Endocarditis Prophylaxis not Recommended

• Negligible-risk Category (no Greater Risk than the General Population)
  • Isolated secundum atrial septal defect
  • Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus
  • Previous coronary artery bypass graft surgery
  • Mitral valve prolapse without valvular regurgitation1
  • Physiologic, functional, or innocent heart murmurs1
  • Previous Kawasaki disease without valvular dysfunction
  • Previous rheumatic fever without valvular dysfunction
  • Cardiac pacemakers (intravascular and epicardial) and implanted defirillators.

Endocarditis Prophylaxis Recommended During Dental Procedures

• Dental extractions
• Periodontal procedures including surgery, scaling and root planing, and probing
• Dental implant placement and reimplantation of avulsed teeth
• Endodontic (root canal) instrumentation or surgery only beyond the apex
• Subgingival placement of antibiotic fibers or strips
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants where bleeding is anticipated.

Endocarditis Prophylaxis not Recommended

• Restorative dentistry (operative and prosthodontic) with or without retraction cord
• Local anesthetic injections (nonintraligamentary)
• Intracanal endodontic treatment; post-placement and buildup
• Placement of rubber dams
• Postoperative suture removal
• Taking of oral impressions and radiographs.

Anticoagulant Therapy

• Patients with prosthetic heart valves; other valvular disorders; or a history of myocardial infarction, cerebrovascular accident, or thromboembolism are frequently placed on anticoagulant therapy using coumarin derivatives such as dicumarol and warfarin.
• The effectiveness of warfarin and similar agents is monitored by determination of the prothrombin time (PT). Therapeutic level of anticoagulation in a PT of 1.5 to 2.0 times that of the laboratory control PT (>2.0 times control).
• The international normalized ratio (INR) is presently used to determine PT. INR for patients with a normal PT is approximately 1.0. INR values of 5.0 or greater indicate a serious risk of spontaneous bleeding episodes.
• The periodontist may consult with the physician prior to treatment which can induce bleeding to determine whether modification of anticoagulant therapy is indicated. In addition, drug interactions with warfarin and other similar agents are numerous and must be considered.
• Aspirin and other non-steroidal anti-inflammatory drugs may dramatically increase the risk of warfarin-associated bleeding. Tetracyclines may decrease vitamin K production, interfere with the formation of prothrombin, and increase anticoagulation. Metronidazole may inhibit coumadin metabolism, potentiating its anticoagulant effect, while penicillin may counteract coumadin’s effect.
• In many patients, especially those with more moderate levels of anticoagulation requiring relatively minor surgical treatment, no alteration of oral anticoagulants will be required.
• Patients with higher levels of anticoagulation may, after physician consultation, be instructed to terminate their warfarin for 2 to 3 days prior to periodontal procedures due to the long half-life clearance of warfarin (36 to 42 hours). The warfarin is then safely resumed immediately after treatment since several days will pass before full anticoagulant effect has returned.
• An INR value of 3.0 or below is safe for dental procedures likely to induce bleeding, although at this level local measures such as pressure, primary closure, and topical antifibrinolytic (tranexamic acid) therapy may be needed.
• Aspirin, an inhibitor of platelet aggregation, is often used to prevent thrombus formation. Due to its irreversible binding to platelets, the effect of aspirin lasts at least 4 to 7 days. It is generally used in small doses of 325 mg or less and usually will not significantly alter bleeding time at this dose.
• Higher doses may, however, increase bleeding time and predispose to postoperative bleeding. For these patients, aspirin may be discontinued for several days prior to the dental procedure if therapy is expected to induce significant bleeding.

Bleeding Disorders

• Periodontal therapy for patients with bleeding disorders is directed primarily toward early diagnosis and conservative treatment. The patient’s clinical history and any previous signs of excessive hemorrhage are important indicators of potential bleeding problems during treatment.
• While surgical therapy can be successfully performed, extensive surgery or extraction is generally avoided, if possible. Patient education beginning at a young age and excellent oral hygiene to prevent inflammation and disease progression are emphasized.
• Probing, scaling, and prophylaxis can generally be performed without medical modification. If more invasive periodontal treatment such as local anesthetic injection, root planing, or surgery is required, consultation with the patient’s physician may be indicated.
• Preoperative administration of agents such as1-deamino-8-D-arginine vasopressin (DDAVP), factor 8 concentrates, or factor 9 concentrates may be required and the patient may require hospitalization in some instances.
• Laboratory assessment of bleeding time, prothrombin time (PT), activated partial thromboplastin time (aPTT), and/or thrombin time (TT) may be indicated. Local measures to ensure clot formation and stability are of major importance.
• Pressure application, complete suturing, and pressure dressings or stents will reduce hemorrhage.
• Antihemostatic agents such as oxidized cellulose or purified bovine collagen may be placed over surgical sites or into extraction sockets. The antifibrinolytic agent epsilon-aminocaproic acid (EACA), given orally or intravenously, is a potent inhibitor of initial clot dissolution and is especially useful in patients with hemophilia or von Willebrand’s disease.
• Tranexamic acid is a more potent antifibrinolytic agent than EACA and has been shown to prevent excessive oral hemorrhage following periodontal surgery and tooth extraction. It is available in a mouth-rinse form which may be used either alone or in combination with systemic tranexamic acid for several days after surgery.