Management of medically

compromised patients in oral surgery

 Learning objectives
You are expected ,
1. To take thorough medical history that is relevant to the Mx of patients in
oral surgery
2. To practice review of system for various symptoms that patient is
presenting with.
3. To assess medical risk in oral surgery patients.
4. To be able to record vital signs and their interpretations.
5. To know Mx modifications when dealing patients with compromised
medical status
6. To sense professionalism when dealing patients with systemic diseases
7. To be aware of current trends and controversies in Mx of such patients
8. To be aware your specific community needs
 Key points in history and examination of
medically challanged patients
• Either attending surgeon can take history by himself /herself or
may use a questionarre / form at clinic.
• Keeping in consideration , our specific situation and needs,
attending surgeons are urged to take history establish their own
judgment.
• Key enquiry must include common problems , like angina, MI,
arrythmias , rheumatic heart disease,diabetes mellitis, bleeding
disorders, therapeutic anticoagulation, lung diseases, hepatitis,
renal diseases, seizures, stroke, implanted devices ( heart valves,
joints etc) , allergies
• Consider pregnancy /likely hood of pregnancy in child bearing
age patients
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 Review of system/ systemic enquiry /
systemic review
• ROS is sequential and comprehensive method of eliciting
patients symptoms on organ basis.
• Sometimes patients present with undiagnosed medical
condition, ROS helps in uncovering those symptoms.
• Each systems has its own set of questions need to be
asked.
For example: a hypertensive patient with otherwise apparent
no history of cardiac disease should be asked about,
exertion dyspnea, poor exercise tolerance , chest pain on
exertion, orthopnea, peripheral edema, limb claudication,
palpitation and episodes of dizzines or faints
 Assessment of medical risk in surgical
patients
• Various methods of MRA exist, but ASA
grading is the most popular one.
 ASA Classification
Class 1 Healthy
Class 2 Mild systemic disease, no functional limitations
Class 3 Moderate to severe systemic disease, functional
limitations
Class 4 Severe systemic disease, constantly life
threatening, functionally incapacitating
Class 5 Not expected to survive with or without surgery
24h
Class 6 Organ Donor
Class E Emergency
8
General modification according to ASA grade

• ASA 1 and 2 don’t require any modification in

treatment.
• ASA 3 and 4 needs significant modification in
management and are best managed in
hospital setting rather than office.
Management of patients with CAD/IHD

• CAD/IHD comprises of group of diseases that

includes, stable and unstable angina and
myocardial infarction.
• Due to narrowing of coronary artery , during
exertion or increased myocardial activity
oxygen supply doesn’t meet the supply and
leads to myocardial ischemia or infarction.
• Revascularize-------- thromobolysis/ angioplasty/
bypass graft

• Reduce workload------- Ca channel blockers/ beta

blockers

• Rehabilitate------- life style modification/ control of

diabetes or hyperlipidimia /prevention of
thromboembolism( aspirin, clopidogrel , ticlopidine)
 Mx of CAD/IHD in oral surgery
• Elective procedure should be avoided with in 6 months of
recent MI
• Objective of management in oral surgery is to avoid factors
that may trigger ischemic event or increased myocardial
oxygen demand
• Reduce anxiety and stress--- anxiolysis and adequate pain
control
• Reduce epinephrine
• Stop antiplatelet only if cardiologist suggest so or
major/extensive surgery to be done
• Consider drug interactions
 Management of patient in oral surgery with
diabetes mellitis
• DM is an endocrine disease resulting either due to
decreased insulin production or increased insulin
resistance leading to multiple metabolic
consequences related to CHO, protein and lipids.
• Primary DM---- TYPE 1--- decreased or absent insulin
TYPE 2--- Increased insulin reistance
Gestational diabetes
• Secondary DM---- pancreas demage, cushings
diasease, steroid Rx, pheochromocytoma
 Mx of patient with DM
• Objective is to maintain blood glucose levels
below 180 mg /dl thus reducing complications of
DM
• General management comprises of
• Diet alone with life style modifications.
• Oral hypoglycemic agents
• Insulin ( short acting.. 2 hrs peak 6hrs duration,
intermediate acting.. 8-12 hrs peak 24hrs, long
acting .. >16hrs peak 36hrs)
 MX of DM in oral surgery
• Entire management revolves around
prevention of hypoglycemia !
• There is no evidence of “safe glucose levels
"for elective oral surgery procedures but
normal or close normal ensures decreased
post op :complications
Mx of DM patients in oral surgery
• There is no evidence that DM patients are at
more risk of developing post op infection but
they have difficulty in containing infection
once developed
• Prophylactic antibiotics among DM patient is
controversial and inconclusive but practiced
by some surgeons
Management of patients on systemic steroids

HPA AXIS

Sleep+
stress+circadian Pituitary gland
Hypothalamus Adrenocorticotr
Corticotropin pin
releasing
hormone(ACTH)
hormone(CRH)

Adrenal gland
Cortisol
Management of adrenally supressed patients

• Who should be considered as adrenally

supressed?
• 1. patient currently receiving systemic
steroids( prednisolone >7.5mg/day)
• 2. patients who had received systemic
steroids during past year for > 30 days
• 3. regular consumption of steroids during last
30 days
Management of patients on systemic steroids

• Objective of management is to provide

exogenous steroid that patient is unable to
synthesize endogenous steroid due to adrenal
suppression, in case of surgical stress.
 Management of adrenally suppressed
patients

Minor Procedure ●
For those currently receiving steroids
●
Double the dose of steroid OR 25-50mg hydrocortisone I.V pre-op
under local ●

●
Continue regular dose post op
For those who received steroid during previous 12 months
●
Usual dose of steroid OR hydrocortisone 25-50mg I.V pre -op
anesthesia

Procedure ●

●
For those currently receiving steroid
Double the dose plus 25-50mg hydrocortisone I.V pre-op and I.M 6
hourly for 24 hours
For those who received steroid during previous 12 months

under GA
●
Give usual dose of steroid plus 25-50mg hydrocortisone I.V pre –op and
I.M for 24 hours
 Management of patients with end stage
renal disease
• Kidney regulates, water and electrolyte
homeostasis, excretion of toxic products and
drugs, regulates blood pressure, activates
vitamin D, and contributes in erythropoiesis
 General management of ESRD patients

• management of blood pressure

• Salt, potassium and water restriction
• Erythropoietin
• Vit D supplements
• Renal replacement therapy----- either dialysis
OR transplant
 Management of patient on hemodialysis in
oral surgery
• Key consideration:
• 1. best time for oral surgical procedure is the day
next to dialysis
• 2. these patients carry risk of bleeding
• 3. blood borne hepatitis is also common
• 4. increased risk of infection
• 5. nephrotoxic drugs to be avoided
• 6. secondary hyperparathyroidism leads to
osteodystrophy and brown tumors
 Management of patients with renal
transplant
• In addition to previously mentioned :
• 1. these patients are kept on immunosuppressive
drugs therefore are at risk of opportunistic as well as
post-op infection.
• 2. corticosteroids are frequently included in regime,
therefore adrenal suppression need to be considered
• CONSULTATION WITH PRIMARY PHYSICIAN ENSURES
OPTIMUM CARE WITH LESSER RISK OF
COMPLICATIONS !
Secondary issues in organ transplant patients

• Graft versus host disease

• Complications of immunosuppressive drugs
 Management of patient with chronic liver
disease
• Viral hepatitis (B,C and E) may undergo chronic
course after acute infection. Drugs, alcohol and
autoimmune disorders may also cause CLD.
• Chronic hepatitis patient may present like
chronic asymptomatic carriers..or… with
chronic hepatitis …. Or .. End stage liver
disease due to cirrhosis or hepatocellular
carcinoma
 Management of patients with chronic liver
disease/ ESLD
• Liver is responsible for CHO metabolism,
detoxification, drug metabolism, protein
synthesis (including plasma proteins and
clotting factors), digestion of fats, absorption
of fat soluble vitamins.
 Management of patients with chronic liver
disease and ESLD
• Key points:
• Cross infection considerations
( viral load or stage of infection)
• Intraoperative and postoperative bleeding
(platelet count , clotting factors levels, PT and APTT)
• Drug metabolism
• Drug induced liver insult
• Risk of infection
 Management of patients with chronic liver
disease/ ESLD
• Asymptomatic carriers and chronic carriers
without significant liver disease are managed
without any modification in management.
• Patients with liver dysfunction need
modification in management.
• Patients with end stage liver disease are true
jeopardy