Preoperative evaluation of patient's dental health

Preoperative evaluation of patient's dental health

Author:

HM Altaf Malik

Department of Oral and Maxillofacial Surgery

Govt. Dental College, Srinagar.

The co-authors:

Dr. Shah Ajaz A

Associate Professor and Director of

Department Oral and Maxillofacial Surgery

Govt. Dental College, Srinagar.

 

Mr. Suhail Lato

Speaker

Department of Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Manzoor Dr. Ahmad Malik

J & K Health Services, SDH Banipora

 

Tabasum Dr. Rubeena

Resident

CD Hospital, Srinagar.

Dr. Shazia Qadir

Department of Surgery Oral and Maxillofacial

Govt. Dental College, Srinagar.

INTRODUCTION

 

Knowledge about the patient's medical condition is of paramount importance in patient management and treatment of pre and post surgery. A detailed history medial to the all necessary doctor. The relevant information concerning the patient's general condition and physical condition

Classification System physical fitness

In 1962, the American Society of Anesthesiologists adopted the ASA Physical Classification System. This system identifies the risks doctors of a patient undergoing surgery. The classification system is:

ASA I: A patient without systemic disease, a normal, healthy patient

ASA II: Patient with mild systemic disease

ASA III: patient with systemic disease that limits activity break, but not disabling

ASA IV: patients with an incapacitating systemic disease that is a constant threat to life

ASA V: moribund patient not expected to survive 24 hours with or without surgery.

ASA E: emergency operation of any kind, E above the number of ASA, indicating the physical condition the patient.

Heart disease.

While all types of heart disease have a high risk of serious complications during surgery under general anesthesia, some conditions such as unstable angina, congestive heart failure, heart valve septal defects, and increase the risk of myocardial infarction four folds. A history of bypass, angioplasty or valve replacement is of great importance. Although cardiac disease is not absolute importance. Although heart disease is not an absolute indication-cons, the surgeon must weigh the benefits and risks before deciding the choice of anesthesia.

Preoperative Investigations

1. 1. Routine chest X-ray View later.
2. 2. Electrocardiogram
3. Echocardiography

4 Stress Test

1. The research as blood lipid profile and bleeding time, clotting time and prothrombin time and the index of the patient is under long-term anticoagulant

Preoperative drugs

If the patient is a case of rheumatic heart disease or having undergone valve replacement, appropriate antibiotic prophylaxis should be administered. If the patient is penidura infusion every three weeks, the operation should be out immediately after the dose to reduce the risk of infective endocarditis. Patients on long-term anticoagulant therapy should leave at least 5 days 4 Anticoagulants before surgery with the consent of the physician. If the interruption of oral anticoagulation is not recommended, the patient should be transferred to anticoagulants such as intravenous heparin. bleeding time and the point of bleeding the patient is checked in the day of surgery after the failure of anticoagulant.

Intra and postoperative management

1. All patients should be monitored during and after surgery by means of ECG, pulse oximetry, and arterial line.
2. Central venous pressure (CVP) cut can be made if necessary.
3. The patient should be maintained in intravenous drug heart intravenous to oral feeding are given
4. fluid overload should be withdrawn, especially in cases of congestive heart failure. The fluid volume can be judged by the superior vena cava.

HYPERTENSION

Hypertension considering the elevation of blood pressure above 140/190 mmHg.

Uncontrolled hypertension can have complications after surgery and anesthesia.

1. Reflect on the patient's cardiac status, which increases the aesthetic one of the complications
2. Reflect on the role heart, which increases the risk of anesthesia for the patient.
3. Cause excessive bleeding site operations, which complicates surgery and blood loss for the patient.

Preoperative investigations

1. Safe View previous post radiography for the detection of cardiac hypertrophy.
2. ECG
3. USG kidneys
4. pailledema complete eye and retinal hemorrhage.

Renal function tests (blood urea nitrogen in serum creatinine and serum electrolytes).

Preoperative medication and management

patient's blood pressure should be monitored and controlled within normal limits before surgery allows surgery. If the patient is antihypertensive drugs, the dose of medication in the morning before surgery should be administered with sips of water.

and operational management of intra-post.

1. Blood pressure should be monitored continuously during and after surgery.
2. the cardiac status should also be checked at the ECG machine and pulse oximeter.
3. Antihypertensives will continue intra-and post-operatively.
   1. If the patient is treated with diuretics, the patient should be completed after the operation with potassium supplements intravenously.
   2. If the procedure is performed under local anesthesia, then Local bupivacaline aneasthetic or without epinephrine, which has no significant effect on cardiac function should be used.

 

RESPIRATORY DISEASE

Diseases respiratory disease can be classified obstructive pulmonary infiltrate. Pulmonary disease including chronic obstructive pulmonary obstructive similar conditions, asthma, bronchitis chronic emphysema and pneumothorax. infiltrative disease is inclusive of the diseases that cause inflammatory changes in the alveolar walls. Any respiratory disease is characterized initially because of dyspnea.

The patient with decreased pulmonary reserve is a significant risk to the procedures under general anesthesia. Patients should be asked a complete history of beedi / cigarette and a history of tuberculosis. If the patient has tuberculosis, the details of their medication and duration of treatment is necessary. From surgeon's perspective the most important aspect is the patient's respiratory reserve and its ability to tolerate general anesthesia. If patients treated with local anesthesia bronchodilator inhaler should be ready for emergency use.

Preoperative Investigations

1. routine chest radiograph – rear view.
2. pulmonary function tests.
3. investigations such as blood arterial blood gas.
4. Sputum AFB and culture.
5. Bronchoscopy, if needed

The patient should be advised to stop smoking bidi / before the procedure. Any acute infection should be treated with antibiotics. The patient should be in the bronchodilator pre, during and after surgery. The patient must carry your inhaler with him for a in case of emergency.

Intra-and postoperative

1. Pressure control of blood gases also must perform during and after surgery.
2. Avoid excessive fluid
   1. Blood loss must be replaced by whole blood or packed red blood to prevent a reduction of blood to carry oxygen.

RENAL DISEASES

Patients with renal insufficiency, renal failure, acute glomerulonephritis, nephrotic syndrome and pose a significant risk surgery. Alterations in the function leads to changes in renal acid-base serum calcium and phosphorus, water retention and electrolyte concentration. One patient with infection chronic sepsis can develop after surgery. These patients also have associated hypertension secondary to fluid retention and anemia.

preoperative investigations.

1. Profile cretinine urea renal blood serum, serum electrolytes.
2. clearance test creatinine.
3. Serum calcium and phosphorus.
4. Urinalysis and microscopic-physical.
5. USG kidneys.
6. Renal Doppler.
7. Scan time for the renal clearance

and the subsequent management of the operation within

1. fluid balance, acid-base and electrolyte balance should be closely monitored.
2. testing Renal profile should be performed within the operative and post.
3. blood replacement washed red blood cells.
4. potassium load during replenishment liquids should be avoided.
   1. The patient should be covered with broad spectrum antibiotics to prevent sepsis. Like most antibiotics are excreted by the kidneys, only a few have been proven safe. Amoxicillin, doxycycline and minocycline are some of the recommended antibiotics.

MANAGEMENT transplanted kidney

1. renal transplant patients in the category of the American Society of risk Anaesthsiologist III (which require medical consultation)

2. Reduce stress

Patients should receive adequate rest, waiting.

Appointments should be short.

Benzodiazepines and barbiturates can be used in normal amounts.

nitrous oxide oxygen combination is a good anxiolytic.

Maintain a non-threatening environment.

appointment in the morning.

Consultation with the patient's physician of the need for additional steroids.

dose steroids may be doubled yesterday, the day of, 2 days after the dental procedure.

Graft survival -> 90% in one year with a mortality 5% overall

Patients need to immunosuppression with corticosteroids steroids saving more (azathioprine) cyclosprim raft to prevent rejection.

Treatment:

People with symptoms of renal failure and chronic treatment CRF

> Immunosuppression + steroid antibiotic prophylaxis.

Common hepatitis patients stay away from the source of infection

Candidiasis .- topical nystatin amphoterecin, miconazole

Patients treated with immunosuppressants for renal transplantation are at risk for development – a malignancy (lymphoma, skin, Kaposi's sarcoma and cervical cancer lips) leukoplakia

 

The medicine can be used transmutation of kidney patients

SaferDrugs-Cloxoacillin, penicillin, minocycline, erythromycin,

Refampicin, lidocaine. Chloral hydrate, diazepam

Especially Ampicicilin safe, amoxicillin, benzylpenicillin clotrimazole,

metronidozole, codeine, barbiturates, phenothiazines.

Less Aminoglycosites cephalosporin sure pracetamol, acetoaminophin,

pethidine, opioids, antihistamines

Avoid sulphonaimides tetracycline drugs, NSAIDs and aspirin

 

Hepatic

Preoperative Research

1. Liver enzymes, SGOT (serum glutamic oxaloacetic transaminise)

SGPT (serum glutamic transaminse pyruvic).

1. total bilirubin, direct bilirubin and indirect.
2. serum albumin.
3. serum alkaline phosphates.
4. The bleeding time and clotting time.
5. The prothrombin time and index finger.
6. USG of the liver.
7. test antigen in Australia.

and the subsequent management of the operation within

1. Avoid unpleasant gas that is metabolized in the liver, such as halothane.
2. The correction of deficiencies of coagulation IV vitamin K, fresh frozen plasma transfusions.
3. Administration intra and postoperative care blood volume, cardiac output, urine volume and co0mposition.
4. Supplementation potassium for fluid shifts.
5. Appropriate precautions and sterilization techniques to prevent transmission of the disease in a carried hepatitis virus.

DIABETES MELLITUS

Diabetes mellitus is caused by an absolute or relative deficiency insulin in the body can be classified into type 1 (insulin-dependent) and type 2 (insulin-dependent). Type 1 is most common in young patients with type 2 diabetes in adults. A patient can be considered as a diabetic when their fasting blood glucose levels are above 140 mg / dl.

The nature of the problems encountered by the surgeon in the management of a diabetic patient to know the following.

1. The optimal levels of blood glucose should be maintained during the procedure and postoperatively to prevent hypoglycemia or hyperglycemia and ketoacidosis. The two conditions can be life threatening for the patient.
2. The patient is vulnerable to infection and should provide sufficient pre-and postoperative broad-spectrum antibiotics to prevent infection.
3. The patient may have other systemic complications, such as renal disorders, heart and eye problems and generalized vascular disease due to diabetes of long standing.

For surgical use Diabetes can be classified into three groups:

1. Sugar levels controlled with diet and oral hypoglycemic agents.
2. controlled type of sugar by insulin.
   1. "The brittle diabetes, usually appear under whose metabolic needs is lability and following a long illness, such as insufficient renal vascular disease retinopathy, and generalized.

usually elective surgery can be performed without complications in the first two types. In the third type, although management remains the same, amore rigid intra-and postoperative control.

Preoperative Investigations

1. View posterolateral routine chest radiographs.
2. Electrocardiogram
3. Blood investigations, such as:

a. Fasting and postprandial

b. Tolerance test glucose

C. renal profile (urea, SC, SE)

1. Sugar in the urine.

If the patient is on oral hypoglycemic agents, he / she should move to insulin in the day of surgery. The general principle for managing the patient under general anesthesia is to provide at least 200 grams of carbohydrates with enough insulin to meet this need.

The sugar and insulin

Sugar (mg%) of insulin

Normal 80-120 5% dextrose (D)

120-180 4 units of dextrose 5%

180-250 8 units of 5% dextrose

250-300 14 units in dextrose 5%

300 and more than 14 units in a normal saline

-Surgery and after-Intra

1. Check the patient's blood and sugar levels urine in the morning of surgery with the help of tapes and urostrips hemoglucose or meter.
2. Prepare a sliding scale insulin followed during operation on the basis of sugar in the blood of the patient.
3. Pre-and postoperative broad-spectrum antibiotic coverage.
4. Intra-and postoperative close monitoring of daring and blood sugar in the urine.
5. Prevents the patient from going into ketoacidosis or hypoglycemia.

The signs of hypoglycemia: The patent relates to anxiety, agitation, clammy skin is pale, and there is a tachycardia. The gaps in patient status coma.

Treatment: In a conscious patient, now there are carbohydrates to raise blood glucose levels. In an unconscious patient intravenous administration 50% solution of glucose restores consciousness within 5 to 10 minutes or 1 mg intramuscularly glucogon restores consciousness within 15 minutes.

 

The signs of diabetic ketoacidosis: vomiting, tachypnea, Kussmaul (deep, rapid breathing, at regular intervals) respiration, dehydration and circulatory collapse.

Treatment: The administration of insulin to normalize the body's metabolism and restoration of body fluids and electrolytes.

6.Shift the patient as soon as possible to their regular food and oral hypoglycemic agents.

Thyroid

Patients with disorders can be classified into 3 groups – hypothyroidism, hyperthyroidism and euthyroid. In euthyroid patients pose no risk to any surgery. While hypo-and hyperthyroidism, surgery is best postponed until the patient is euthyroid.

The significance of hypothyroidism include water retention and mucopolysacharide, decreased metabolism processes leading to bradycardia, constipation, and hypothermia letheargy. Untreated hypothyroidism patients do not respond well to stress and to proceed Myxedema coma.

Hyperthyroidism led to a hypermetabolic state in the body resulting in a catabolic state of tachycardia, diarrhea, intolerance heat. If the patient is under stress, or towards what is called a "thyroid storm", which is a metabolic state of hyperactivity lasting 24 to 48 hours. This is a serious exacerbation of the signs and symptoms of hyperthyroidism and is often accompanied by hyperthermia. The condition is potentially fatal and requires monitoring of hyperthermia, tachycardia and heart failure.

Preoperative investigations

1 thyroid hormone – T3, T4, TSH

serum electrolytes 2

3 Whey Protein

4 radionuclide thyroid gland of the study.

Intra-and postoperative management.

1. To control the level of intra-and postoperative hormone

2. Continuous monitoring vital signs, the blood pressure, pulse and

Temperature.

3. Check the signs and symptoms of hypo / hyperthyroidism

4. Continuous monitoring of cardiac function, especially during the crisis of the thyroid. Infuse thyroid hormone if the patient shows signs of hypothyroidism.

5. If the patient is in a thyroid storm, treatment by cooling the patient by intravenous infusion of glucose and glucose IV fluids and corticosteroids

6. use of drugs and anesthetics in hypothyroid patients carefully, as it can be very depressing.

The adrenal disease.

Two common adrenal to be addressed during surgical procedures are Cushing's syndrome (overproduction) and Addison's disease (in production)

Symptoms of Cushing's syndrome are diabetes, retention of sodium and water excretion of potassium, hypertension and fat redistribution. Patient also has a tendency to osteoporosis, poor healing of wounds and purple training. During surgery, attention should be paid to maintain optimal levels of carbohydrates in the body, sodium and potassium ions in blood pressure. Bleeding problem can be post-operative and delayed healing.

The deputy may occur due to adrenal suppression due to exogenous steroids or because of an adrenal disease Disease (Addison). In general, all patients who received steroids for more than two weeks in a year before the surgery should be considered as a candidate for adrenal insufficiency.

Preoperative investigations

1.Renal profile.

2.Serum electrolytes.

3.Fasting blood sugar.

4.Platletcount.

5.Coagulation profile.

Adrenal insufficiency patients should be supplemented with Exogenous steroids before surgery to help control the patient with stress

 

and operational management of intra-post.

1.Continuous monitoring vital signs.

2. Adequate supplementation intravenous corticosteroids to prevent adrenal insufficiency acute.

3. Maintaining the balance of fluids and electrolytes.

4. Monitor blood sugar levels in the blood.

Neurological

Neurological disorders can be classified in patients cerebrovascualar disorders, seizure disorders and patients with head injury. major factors account for these patients is sufficient to maintain cerebral perfusion within-and postoperative and control of any episodes of crisis during this period. Patients with seizure disorders are usually not cause a big problem for the management of intrauterine devices with the exception of cases of state asthamaticus, where you can have life-threatening complications. The surgeon must weigh the risks and benefits of heart attacks, aneurysms and malformations are very high-risk candidates and indications absolute contra-areteriovenous surgery.

Preoperative investigations

skull radiographs views 1.Routine back and side.

2.CT CT / MRI.

3.EEG.

4.Liver function tests.

If the patient is epileptic, a adequate control of the episodes from the wall should be carried out before surgery. Anticonvulsants should be continued until the morning of surgery. The dose is given in the morning with a sip of water.

and the subsequent management of the operation within

1.The patient should be administered anticonvulsants intravenously during the operation.

2.Postoperatively the patient should be moved to its normal dose of anticonvulsants, as soon as possible.

3.Throughout the procedure, hypotension / hyoxia be avoided and adequate cerebral perfusion must be maintained.

Disorders Hematopoietic System

Hematopoietic system disorders can be grouped into anemia, disorders of leukocytes and abnormalities of the factors coagulation (hemophilia). Anami include iron deficiency anemia, thalassemia, sickle cell anemia and disorders of leukocytes include leukocytosis and agranulocytosis.

Any disruption in the hematopoietic system

1. Predisposes the patient to a prolonged bleeding during surgery, which can not be controlled by routine hemostatic.

2. May cause severe internal bleeding due to blunt intubation after an injury, unnoticed if a state can do a potentially lethal complication.

3.Leukemic and thalassemic patients may be repeated blood transfusions and may have liver problems caused by excessive deposits of hemosiderin.

4.The rate of postoperative infection and delayed healing is also very high, especially in cases of agranulocytosis, leukemia and anemia.

preoperative investigations.

1.Complete blood count

2.Bleeding time and clotting time.

Time and index 3.Prothrombin

4.Partial thromboplastin time.

5.Coagulation factor analysis exchange (in the case of anomalies of the factors).

6.Platlet count

7.Haemoglobin.

8.Liver function tests

Before the procedure, the patient's blood count normal values should be established by the transfusion of whole blood cell concentrates, plasma components or plasma and clotting factors. In hemophilia, factor VIII must be a minimum of 50 to 70 percent before the procedure. When blood levels are normal, the patient can be treated as a normal patient about the surgery ready for transfusion during surgery, if necessary. In case of leukemia, the patient should be covered with spectrum antibiotics before and after the operation.

Intra and postoperative management

1. Avoid excessive trauma to the tissue during a procedure performed.

2. Avoid going into the deep tissue spaces in the dark, This prevents any internal bleeding.

3. Complete hemostasis must be achieved before wound closure.

4. Intraoperative blood transfusion or blood products if necessary.

5. Monitoring of hemoglobin, blood count intra-and post-operatively.

6. Maintaining adequate blood volume during the procedure and at the same time avoid cardiac overload.

7. Vital signs monitor closely any changes in fluid volume indicated by the pulse and blood pressure.

8. Postoperatively, the patient can be maintained in the oral systemic coagulants such as vitamin K for 3-5 days.

9. Cover the patient with antibiotics appropriate broad-spectrum.

10. Avoid drugs that may worsen the underlying, especially in agranculocytosis.

Given the increased load in the blood transmission of diseases such as AIDS, hepatitis B and hepatitis C, the government has ordered testing of all three viruses before storing the blood at the blood bank. But the decision transfuse blood and blood products remains to be done carefully weigh the risks and benefits.

Management a patient with hemophilia

 

Hemophilia is usually of two types, Hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). The disorder is a sex-linked recessive trait.Approximatley 50 percent of girls are carriers of the disease and 50 percent of the offspring Males have a bleeding disorder. these patients have a bleeding disorder. These patients tend to bruise easily and prolonged bleeding.

Successful management depends on maintaining a hemophiliac adequacy of antihemophilic globulin. AHG normal level is 50 to 100 percent. As a hemophiliac, good for hemostasis, the factor should be 20 percent above normal, but a normal level is also acceptable.

thromboplastin time of regeneration not only determines the factor VIII deficiency, but also distinguishes it from the deficiency of factor IX. Replacement of factor VIII may be provided by the blood, plasma, fresh plasma frozen and cryoprecipitate. This last option is the alternative because it offers only the deficient factor.

Administration

1. construction factor of the VIII level 50 to 70 percent.

2. Do not inject into areas of deep tissue, which is to avoid printing techniques. The use of infiltration anesthesia.

3. traumatic surgical excision procedure.

4. Tips to avoid unnecessary trauma to soft tissues, avoiding suture if necessary.

Immunocompromised patients

Patients may be immunosuppressed grouped with patients who have poor cell-mediated immunity, humoral neutorphils complete, patients on immunosuppressive drugs and chemotherapy agents and steroids, and patients with long-term debilitating diseases such as diabetes and nutritional deficiencies.

These patients are very susceptible to infection and should be administered

Broad-spectrum antibiotics for same.

 

 

preoperative investigations.

Bloodlines

Liver function tests

renal function tests

Serum proteins

Sugar blood.

urinalysis.

Routine chest radiograph.

and the subsequent management of the operation within

The location varies by state the patient is suffering. In general, it is almost impossible to correct the causative factor and treatment is usually favorable only.

Constant monitoring of vital parameters.

coverage with broad spectrum antibiotics.

Although management of patients infected with HIV, should be given special care to avoid disease transmission.

Autoimmune

 

The group of autoimmune diseases such as lupus erythematosus, scleroderma, connective tissue diseases, arthritis rheumatoid Shjogren syndrome, polyartertis knotty, etc. These patients may have significant cardiac, renal and bone marrow, which can be cons elective surgery. Patients, as far as possible be used during remission. Some of these patients are treatment corticosterioid the long term, as therefore precautions to prevent adrenal insufficiency should be taken.

Some of these patients have a loss of flexibility in the joints, especially chest and joints of the neck, which poses problems in intubation and ventilation. Ask intubation and ventilation problems. In scleroderma patients have a limitation of mouth opening and limited expansion of the chest wall.

Patients with collagen disorders may also have delayed wound healing the wound after the operation.

Pregnancy and lactation.

 

Each patient of childbearing age should be asked for the history of pregnancy calls menstrual cycles. Great care must be taken in treating the pregnant patient to the surgeon must address not only the mother but also to prevent inappropriate damage to the fetus. It is safe to perform procedures under local anesthesia in the second quarter. During the first quarter, the risk of stress related abortion and teratogenicity, while in the third quarter there is a risk of induced stress, while the third quarter there is a risk stress-induced onset of labor. General anesthesia is a con-indication in the third quarter, except for emergency life-saving in the third quarter, except to save the life of the emergency procedure. In the care of first and second quarters should be taken to prevent fetal anoxia.

Again, the risks and benefits must be weighed before the procedure, the mother should be told about the risks before proceeding. The mother should be fully explained the risks before proceeding. teratogenic drugs such as tetracyclines, salicylates, chloramphenicol, and is best avoided. Amoxicillin, cloxacillin, ampicillin and paracetamol can be prescribed safely.

CONCLUSION

To conclude this chapter, several points should deserve noted that define a basic protocol to follow in the management of a medically compromised patient.

Through the knowledge of patient's medical history should be obtained.

The surgeon should also have knowledge of the drugs taken by the patient and the regularity of taking the same patient.

Written consent for surgery must be obtained from a specialist in the field before the procedure.

Appropriate and necessary Preoperative investigations should be conducted.

The patient should be informed about the risks and benefits of proceeding with respect to their general and authorization writing to witness the proceedings, and consent to a high risk must be obtained from the patient.

The operating room must be equipped with functional support systems vital and an emergency cart updated in case of emergency. The same applies to the recovery room after surgery.

The decision whether to apply or not with the surgeon and he / she must make decisions weighing the advantages and disadvantages risks with respect to the benefits of surgery and anesthesia

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