BY DR.MUTANGILI ORAL&MAXIOFACIAL SURGERY K.N.H CLINICAL CONSIDERATION BEFORE MINOR ORAL PROCEDURE

MINOR ORAL PROCEDURE  A minor surgical procedure either clean or sterile performed under local anaethesia and lasting for not more than 1 hour. RE: Australian Dental Council

MEDICAL CONSIDERATION  Taking into account medical conditions pre-existing prior to a surgical procedure that may impart negatively (intra-operative; immediate post operative, or long term post operative) on the safety and well being of the patient.

COMMON MEDICAL CONDITIONS ENCOUNTERED BEFORE MINOR ORAL PROCEDURE INCLUDES:  High blood pressure  Diabetes mellitus  Pregnant dental patient  Haemophilia  Patient on long term anti coagulant therapy(Cardiovascular Diseases) Including (RHD,CHD,CAD,M.I)  Asthmatic patient

 Patient with PTB  HIV patient  Patient allergic to latex  The special patient  The psychiatric dental patient

HYPERTENTION  Clinically comes in two forms:  A know hypertensive  The unknown hypertensive The Known: Already under medication Knows the drugs Normal 120 Systolic 80 Diastolic and below

Mild /80-90 Moderate /91-95 Normal proceed with treatment under local anaethesia without adrenaline Mild/Moderate ; Monitor Alleviate fear, stress & anxiety Review medication Refer for consultation before surgery Severe readings above 139 systolic and 95 diastolic Defer treatment Refer for physician review

 The unknown hypertensive patient  Patient not aware of existing high blood pressure, Common complaints; Hx of frequent headaches Hx of bleeding nose Hx of dizziness Hx of syncope Maybe suffering from high blood pressure Take blood pressure,best practice to take two reading from left and right the do the average. depending on the results proceed as above

Possible complications excess bleeding Excess loss may lead to Hypovolumic shock Longer stay in hospital Unexpected expenses

DIABETES MALITUS(TYPE 1,TYPE 2)  Persistent high sugar levels in blood presents as -A Known Diabetic -The Known The Known - already diagnosed - On medication Normal –Radom sugar 3-6g/dl Fasting sugar 3-4g/dl

 Hypoglycemic <3 (both fasting, random)  Diabetic >9 fasting >10 random Possible Completion -Compromised immunity -Risk of infection post operative -Delayed or failed healing -Possibility of excessive bleeding -Risk of spread of infection to potential spaces(including necrotising fasicitis)

The UNKNOWN  May present: -Polyuria-frequent passing of urine -Polydipsia-increased water intake -Polyphagia-increased appetite - Recent marked loss of weight  Carry out –RBS -FBS next morning depending on results Results of sugar>9g/dl, defer treatment and refer to physician for start, control of blood sugar.

THE PREGNANT PATIENT  1 ST Trimester concern- the inter-uterine life: Precautions on medications that may put the unborn child includes -the use of nitroimmidazole drugs. -X-ray exposure -If X-ray must be taken. -Risk of developing gestational diabetes may be precipitates by dental treatment stress

 3 rd Trimester -Risk of developing hypertension due to hormonal changes and postural changes -Discomfort for longer procedures in supine position -Diminished blood to the foetus -Procedures like MMF may compromise the health of the developing fetus.

PATIENT ON LONG TERM ANTICOAGULAT THERAPY  Warfarin: -Risk of excessive bleeding -Decreased volume worsening an existing cardiovascular diseases  If surgical procedure has to be done -Best managed as in patient -Stop the warfarin 3days to day of surgery -Start patient of short acting anticoagulat drugs

-Clexane S.C. BD -Stop the clexane in the morning of surgery -Do INR-if <1.2 proceed with surgery -Restart warfarin soon after

HEAMOPHILIA  Usually a young boy  Manage as inpatient with consultation with hematologist  Prepare the factor 8 concentrate before surgery ASHMATIC -The antiasthmatic must be readily available in the clinic before surgery can start. Particularly aerosols or nebulizer

 Infective Stages -Schedule as last patient of the day -Use high volume suction to reduce aerosols -Handler must use special face masks(hepa,niosh,NG5)  HIV -Need not be isolated -Must be done under sterile environment -Surgical sites must be cleared with and septic (chlorohexidine/iodine solutions) To avoid introducing new infections

PATIENT ALLERGIC TO LATEX  Increasing  Major challenge, many clinic set ups mainly use latex gloves  Incidences of severe anaphylaxis and even death have been reported Careful History -Patients who report allergy to bananas,kiwis,avocados,watermelon should be suspected to be allergic to latex These fruits contain chemical similar to NRL which is the allergen in latex.

Keep epinephrine ready -Use latex free gloves, tubing and suction tips -Patient should be scheduled as first patient in the morning, cases of reaction from services contaminated with latex have been reported. -May be managed in isolation not near rooms with latex containing material

Q &A

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