Dental Management of Medically Compromis

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Good Morning

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Dental Management of Medially Compromised Patients (2) Dr. Usama M. Madany Prof. Oral Medicine, Periodontology, Diagnosis and Oral Radiology, Faculty of Dental Medicine, Al- Azhar Univer. , Cairo, Egypt.

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The Kidneys The kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure, converting Vit D into its active form, and stimulating rbc production by synthesizing erythropoietin.

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End Stage Renal Disease Deterioration of nephrons resulting in loss of ability to excrete wastes and regulate electrolytes. ESRD almost always occur as acute renal or chronic failure(exist for 10 - 20 years or more) progressing to the point where function is less than 10% of normal. Function is so low that without dialysis or kidney transplantation, death will occur from accumulation of fluids and waste products in the body.

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Chronic renal failure/hemodialysis. Renal transplantation. Renal Disorders

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Problems Increased susceptibility to infection + immunosuppression Bleeding tendency. Decreased ability to excrete drugs. Existence of A-V shunt. Cross infection. Renal Disorders

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Pallor of oral mucosa secondary to anemia. Xerostomia due to medications. Metallic taste and saliva may have characteristic ammonia-like odor due to high urea content. In severe renal failure, stomatitis may be present. Excessive postoperative bleeding. Radiographic changes due to secondary hyperparathyroidis: loss of lamina dura demineralized bone ground glass appearance General Oral Complications

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Chronic renal failure Dental management It is generally preferable to treat patients before rather than after dialysis or transplantation 1-Consult patient’s physician. 2-Monitor blood pressure. 3-Check lab values, PTT, PT, platelet count, bleeding time, blood urea nitrogen (do not treat if less than 60 mg/100ml) and serum creatinine (do not treat if less than1.5 mg/100ml). 4. If medical parameters permits *Eliminate all foci of infection. *Keep only the easily maintainable teeth. *Try to keep good oral hygiene.

Normal Lab Values : 

Normal Lab Values

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5- Avoid prescribing Tetracyclines, streptomycin, vancomycin, gentamycin. acyclovir, acetaminophen, phenacetine, NSAIDs, asprin, antihistamines, phenobarbitones. Decrease dose of Cephalosporins, penicillins,, ampicillin, metronidazole, acyclovir, paracetamol, benzodiazpine. Give normal dose of Cloxacillin, amoxicillin, erythromycin, minocycline, codiene, diazepam, lidocaine.

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Hemodialysis High incidence of serum hepatitis. High incidence of anemia. Significant incidence of secondary hyperparthyroidism. Uremic stomatitis may exists. Undergo heparinization during hemodialysis. Have arteriovenous shunt or fistula.

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AV Fistula AV Graft

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Dental management 1-Screen for HBsAg and HBsAb. 2-Antibiotic prophylaxis to prevent endartritis of arteriovenous fistula. 3-Prevent hypoxia. 4-Provide treatment on the day after hemodyalisis. 5-Be careful to protect the fistula or shunt when patient on dental chair. 6-Refer the patient to physician if uremic stomatitis is noted to develop.

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(1) Diabetes mellitus (uncontrolled) (2) Chronic renal failure (3) Alcoholism, chronic liver disease, cirrhosis (4) Splenectomy (5) SLE (6) Neutrpenia (7) Organ transplantation (8) Sickle cell anemia (9) Chronic corticosteroids usage (10) HIV/AIDS Conditions indicated for prophylactic regimens for dental procedures based on recommendations of American Heart Association

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Renal transplant patient Infection in such patients is life –threatening. Before transplantation only easily maintained teeth should be determined by dental team approach. Teeth with furcation involvements, periodontal abscesses, or extensive surgical requirements should be extracted. Dental management 1- Emergency treatment only for 1st 6 months. 2- HBsAg screening. 3-Prophylactic antibiotics according to AHA recommendations. 4- Erythromycin is contraindicated in patients on cyclosporins. 5-Immunosuppressed patient requires supplemental corticosteroids.

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Supplemental corticosteroids. Hydrocrtizone 100 mg IM injection 30 minutes before procedures. Or Hydrocrtizone 100 mg IV injection immediately before procedures followed by double of normal oral dose. Or - double of normal oral dose at the day of procedure followed by - normal dose + 50% second day followed by - normal dose + 25% third day followed by - normal dose

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Thank you

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