*HIGH RISK PATIENTS IN ORAL SURDERY*

P. With angina pectoris :

Angina pectoris is obstruction of the arterial supply to the myocardium . Cause by arteriosclerosis of the coronary artery . Occurs in Men over age 40 . Symptoms : Heavy pressure or squeezing sensation in the patient's substernal region that can radiate into the left shoulder and arm and mandible region .Stimulation of vagal activity occur with : - Nausea . - Sweating . - Bradycardia. The attack occur by : Exertion, anxiety or during digestion of large meal . Diagnosis : Depend on : - Clinical exam . - ECG - electrocardiogram . Treatment : - Nitroglycerin under the tongue . - I . V valium . - Dilatation drugs for blood vessel . - Inderal 10-40mg /12h et . Dental treatment for patient with A.P.

1- If the Angina pectoris arise only during exertion and respond to nitroglycerin the oral surgery procedure are safe when performed with proper precautions . 2- Uncontrolled angina pectoris surgery should be delay until a medical consultation is obtained . 3- Local Anesthesia without adrenalin or nor-adrenalin . 4- The safe local anesthesia is lidocaine hydrochloride . Cardiac Arrest : - It means suddenly stop breathing and circulation .
Reasons :

1- Drugs : Like analgesic , Anesthetic or hypersensitivity to drugs like antibiotic {penicillin}. 2- Mechanically factors : Like liquid aspiration or foreign body {tooth or anything else} . 3- Heart diseases and pulmonary diseases . 4- Pain {shock} .
Diagnosis :

- Absence of chest movement . - Absence of breathing . - Absence of pulse .

Management :

We must fast began the treatment to avoid the brain damage which happen during 4-6 minute . - Open the airway : - Breathing mouth to mouth or synthetic respiration , - Remove the foreign body - Cardiac massage - I.V drips{liquid}. - 5 ml adrenaline 1/10000 I .V or directly inject to heart . - Atropine if pulse less than 60/ min . 4 massage to one breath {mouth to mouth} .

- For removing foreign body Press manually on the chest .

the patient lay down vertically .

-Follow up the breathing after the removing the F.B .

Hypertension :

We must count everyone who has 90/150 in rest situation after two time taking measures on left and right hand . Normal rate : - Systolic 90140 mm / mercury . - Diastolic Reasons : - 90 % of cases are unknown . - Renal causation . - Heart causation . - Drugs . - Tumors . Symptoms : * Headache . * Ears buzzing . * Vertigo . * Bleeding from nose . Dental treatment : * Specialist Medical consultation . * We can do dental treatment for patient well controlled don't give him adrenalin in local anesthetic solution be taken . * Patient with several hypertension{systolic is 200or more and 110 or more diastolic controlled . Hypotension : delay the surgical procedure until the pressure is better it rise the blood pressure . * If the pat, use antihypertension drugs the morning dose must 6090 mm / mercury .

Systolic is less than 80 . Clinically : * Rush in pulse and breathing . * Agitation . * Nausea . * Vomiting . Reasons : * Drugs using over does antihypertension . * Loosing blood or liquids . * Hypothyroidism . * Heart reasons infarction Management : * Patient lying back with elevate the legs up . * Give O2 . If there is no effect . * Open vein and give fluid{glucose}. Bleeding Disorders : - Un normal bleeding for different reasons . Can grouped into : * Anemia . * Leukocyte disorder . * Coagulation factors abnormality . Any bleeding disorder cause : * Prolonged bleeding which can't be controlled by routine haemostatic . * May cause several internal bleeding . * Postoperative infection and delayed wound healing . Management : * Avoid deep trauma of the pat . * Complete haemostatic must prepared . * Trans fusion of blood or blood product if necessary.

* Give vitamin B complex a vitamin C{they help to form blood cloth and wound healing}. * Give systemic coagulant like vitamin{k}orally 3-5days . * Cover the patient by broad spectrum antibiotic . The bleeding may be : 1- Spontaneous either subcutaneous or submucosa . 2- May be post surgical procedures . Coagulation Mechanism : It depends on : 1- Blood vessel . 2- Blood platelet count . 3- Coagulation factor . Classification is depend on : 1-Reasons : - Immunity diseases in any part of body . 2- Blood vessel : - Purpura . - Allergy . - Alcoholisms . - Infection . 3-Platelet count : - The normal rate is 150-450 thousand / mm3. Less count cause by : Purpura : Drugs . Chemical . * Leukemia . * Splenomegaly . * Infection in the blood vessel . 4-Coagulation factors : * Hemophilia {definition of factor VIII}.

* Crismes disease {definition of factor IX}. Hemophilia : Definition : It is a genetic diseases in men only . It has three types : 1- Hemophilia A insufficiency factorVIII . 2- Hemophilia B insuff.factorXI . 3- Hemophilia C insuff. factor XIII . HemophiliaA : It reasons is insufficiency of VIII coagulation factor it can be : 1- Grievous case : The percent of factor VIII is 1-2 % . It starts in childhood with spontaneously bleeding or after circumcision . 2- Moderate case : The percent of factor VIII is 3-24 % bleeding is discontinuous happen for example post simple extraction . 3- Soft case : The percent of factor VIII is between 25-50 % . Laboratory exam : Coagulation time is prelate{more than 30 minute}. Treatment : No treatment recurs but you must intension about emergency case . In general the bleeding treatment is : * For topical trauma press locally for 5 minute . * Press with swab cotton with adrenaline solution 5 minute . * If blood not stop use trombine powder on the trauma. * Stitch if the wound is wide only . * Acrylic plate which we do before operation . fresh blood or dry plasma . * Blood transfusion - Cold compress .

- Vitamin K and C injection .

- Tea bags{the tannic acid help to stop the bleeding} it use for the longer time bleeding 2-3hours . * The best way is to be given factor VIII before surgical procedures . Stitch must be nonresorable . Important Note : Don't write these analgesic for patient with bleeding disorder : * Aspirin . * Indomethacine . * Ketoprofine . If you want to write analgesic you can write : * Paracetamol . * Codeine . Anemia : Anemia with iron insufficient . Bone marrow can`t product enough red blood cell because of iron is important to form hemoglobin . Causes : * Menstruation-pregnancy or lactation * Children one year old . * Long term using aspirin . * Trauma or gastritis . Symptoms : * Blanching , feel tired , nausea . * Tongue blanching , fissuring the angel of lip . Lab .exam : * Less red blood count and less H B % . * Less iron . Treatment : * Iron sulphate 200 mg / 8 hour per mouth . *Anemia B12 and folic acid insufficient the treatment is B12 and F.A.

Important Note : Don't write Aspirin like analgesic and chloramphenicol for treatment of infection instead of it you can write paracetamol and Ampicilin . Jaundice : It is a yellow color for skin and eye's sclera as result of arising blood bilirubin and it is a clinical view for hepatic diseases . The normal rate of bilirubin is to 10 mg/L . We discover jaundice when the eye's sclera and skin are yellow and blood bilirubin is 20-30mg/ L . It is divided to : Jaundice before liver : The liver cell are healthy and the lesion in the hemolytic of blood . Hepatic jaundice : It cause by infection either A or B or non A,B infection . Post hepatic jaundice : It is congesting jaundice by stones , tumors or obstruction duct . Dental treat : Jaun.patient has yellow mucous membrane and tendency for long bleeding after any surgical procedure . * The best is to delay extraction or another surgical procedure . * Avoid infection trauma by needle . * Use gloves and disposable needles . * If necessary medical consultation . Diabetes Mellitus : It is divided to : 1- Diabetes insulin dependent or Juvenile diabetes . 2- Diabetes Non insulin dependent or adult diabetes. Symptoms first one : - Thirst . - Polyuria .

- Hunger . - Less weight . - Tendency to affected with infection . Symptoms second : 1- Fatty . 2- pruritus . 3- Seeing disorder . Disorders : - Tendency to be affected with infection : - Hypoglycemic coma . - Diabetic coma . - Heart diseases . - Gingivitis ,alveolititis , paradontosis . - Sialoadnitis . - Multiple caries . - Delay the wound healing . Diagnoses : Depends on : 1- Fasting blood sugar more than 140 mg%{normal rate 80-100 mg%}. 2- Random blood sugar two hours after meal more than 200 mg % . Treat : * For the first one we give insulin . * For the second diet control and anti diabetic drugs Dental treat : If the patient without complication you can do the dental treatment with : * Fasting blood sugar to 120 mg % . * Random lees than 200 mg % . * Local anesthetic solution without adrenalin to avoid tissue necrosis and hyperglycemia give vitamin B,C .for healing.

* Patient insulin dependent * For big operations :

let him take insulin and normal meal + lot

of sweets and to be treated in the morning . - Medical consultation and antibiotic . Thyroid Diseases : Divided to : * Euthyroid . * Hypothyroid . * Hyperthyroid . Euthyroid has no risk for any surgical procedure but in both hypo and hyper is best to postponed till the patient is euthyroid . Hyperthyroidism : -You can see it in adult women more than in men . Symptoms : * Exophthalmoses . * Tachycardia . * Less weight . * Anxiety . * Heart and vascular diseases . Dental treat : Every dentist may doubt that patient is affected if he has these symptoms : * Tachycardia . * Without tolerance to hot . * Arising pulse . Treatment : Before extraction - Iode . - Anti thyroid drugs. - Thyroidectomy.

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So : * Consultation . * Avoid General anaesthetize for patient with thyrotoxicosis . Adrenalin is Contraindicated . Thyroid storm : It is emergency case in dental practice with : * High heat agitation tachycardia . * Coma . Management : * Less the heat . * Hydrocortisone 100 300 mg . * Inderal 40 mg / per mouth every 8y . * Drugs of thyroid . * Con . Medical sp . Hypothyroidism : - Adrenaline in local anesthetic solution has no effect. - Avoid to use narcotic drug + barbiturate drugs . Respiratory Diseases : The pat should be asked about asthma or chronic bronchitis . If the pat is treated under L.A the bronchodilator inhaler should be kept ready for use in emergency . Renal Diseases : Patient with renal failure , nephritic syndrome or chronic infection are risk pat . They may develop postoperative sepsis , secondary hypertension or anemia . Management : * Consultation urologist must be done . * Covered with broad spectrum antibiotic to prevent sepsis. * Safe antibiotic are Amoxicillin or doxycyline .

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* Aspirin is contraindicated . Pregnancy woman : The main dental consideration are : 1- Minimize radiographic exposure . 2- Prevent supine hypotension . 3- Avoid hypoxia . 4- Withhold drugs that cross the placenta and damage to the fetus . The stage of fetal development : {first , second or third trimester} is very important for dental treatment . * During the first the dentist give and prevent oral health care . Minimize the likelihood of miscarriage . * Second is the safest time to provide dental care and extraction * Third all routine care should be postponed until the delivery . L . A for pregnancy woman : * Administer intraoral local A .slowly better with aspiration . * Avoid L . A with vasoconstrictor because epinephrine stimulate cardiac activity and elevatesblood pressure . Lactation : L . A . S has effect on the milk of mother and the child feeding . But if it is safety to use procaine,but you must advice mother to feed her child before extraction and a new milk 2 hours after extraction. Menstruation : Don't extraction during first three days to avoid so much{Bleeding}. Prophylaxis for the prevention of infective endocarditis Orally : * Adult over 30 kg :No allergic to penicillin . * Amoxicillin 3 g / hour before dental treatmentthen 1,5 g 6 hour after the initial dose . adult over30 kg .

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Allergic to penicillin or has history of rheumatic fever erythromycin 8oo mg 2hours before dental treatment followed by half original dose 6hours after the initial dose . Intra .V. or I .M . Adult or children over 30kg no allergic 2g ampicilin 30 minutes before treat and 1g ampicilin orally 6 hour after initial dose . For allergic clindamycin 10mg / kg 30min before treat followed by half original dose 6hours after the initial dose . For high risk patient : Non allergic Ampicilin 2g I . V combined with gentamycin 30 min before treat 1,5 g amoxicillin orally 6hours after repeated 6hours after initial dose . Allergic : - Vancomyin 1g I.V slowly before treatment . * Pat with congenital heart defect {unrepaired cong . heart defect}is as above . * For pat who repaired defect within the past 6 mon don't require antibiotic coverage . * Transmissible Viral Infection * Hepatitis : It is hepatic cell destruction by viral infection . It has a number of kinds like A , B , C or D. The most important for dental practice is hepatitis B . Hepatitis A : - It is cause by A virus . - It affect children . - It is without jaundice . - It is spread by mouth, water or stool . - Anorexia : it is the important symptom .

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- Palpation pain on the liver . - Lumph hyperthrophy . Treatment : - Earbohydrate , Vitamines . - Avoid suets . - No special treat . Hepatitis B: - It is important for dental practice . - It cause by B virus . Spread by : Blood transfusion . during extraction or any other surgical procedure . Syrings Narcotics using for more than one patient . drugs . or :

Sexually transmitted . - Don't traumatize your fingers or hands . - Wearing mask and looking glass . - Always send the patient for primary health center for further management . Dangerous factors are: - Homosexual . - Haemophilic . - Hospital's work . Incubation period : Is 1-6 months . The virus is resistant for disinfection and can alive outside of The body . Symptoms : - The main symptom is anorexia . - Fever .

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- Joint pain . - Patient feels tired . Lates : - Jaundice continue for 1-4 weeks . - Hepatomegaly . Treatment : Like the above . Prophylaxe : - Vaccination for all health workers . It is by three injections : - First one . - Second after one month . - The third is after 6 months . Supporting does for protecting, is every five years . Management or Notice : - Treat every patient as he is effected . - Dress gloves when working . - Dress gloves . - Use disposable instrument . - Disinfected the chair and clinic after finishing . The acquired immune deficiency syndrome AIDS - It may primary Transsimated from mother to child . Secondary : - It affect lymph cell B or T or both and decrease the cellMediated imununity . - It cause by HIVI . - Transmitted by : - Sex male homosexual activity heterosexual . - I.V drugs . - Blood transfusion .

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- Contaminated syringe . - Narcotic patient . Decrease immunity can cause this infections : - Fungal infection oral candidosis . - Viral infection - Tumours hairy leukopluku , herpes . gingivitis , paradontosis degenerative gin. aphtosis , delay healing ,decrease - Bacterial infection

kaposiesarcoma .

- Infection with unknown reason platelet cell count .

- Hyperthrophy salivary glands . Notice : - Patient must be treated alone in clinic . - Wearing gloves {D. and sister}. - All instrument must be disinfected using only for this patient . - Disposable needles and syringe must be used .

DOCTOR * AHMED SALEH ASSAEDY *

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