林聰勝中華民國口腔顎面外科專科醫師高醫口腔顎面外科碩士正安牙醫診所高醫口外臨床指導醫師高醫大口腔醫學院兼任助理教授Ankylos 臺灣區教育訓練講師南台灣牙醫植體醫學會理事長

Considerations of Considerations of systemic disease in OMFS systemic disease in OMFS

林聰勝林聰勝

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Rheumatic fever and rheumatic heart diRheumatic fever and rheumatic heart disease …infective endocarditis (2g PC)sease …infective endocarditis (2g PC)

• Congenital heart disease … infective enCongenital heart disease … infective endocarditis , prolong bleeding time(throdocarditis , prolong bleeding time(thrombosis in small vessels)mbosis in small vessels)

• Surgical corrected cardiovascular lesionSurgical corrected cardiovascular lesions …anticoagulant prolong bleeding time s …anticoagulant prolong bleeding time , endocarditis, endocarditis

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Artificial heart valves …anticoagulant prArtificial heart valves …anticoagulant prolong bleeding time , endocarditisolong bleeding time , endocarditis

• Premedication : amoxicillin 2g , child 50Premedication : amoxicillin 2g , child 50mg/kgmg/kg

• Heart transplant : suppression of immunHeart transplant : suppression of immune, anticoagulant, high steroid , may neee, anticoagulant, high steroid , may need supplementationd supplementation

AHA AHA Prevention of Infective Prevention of Infective Endocarditis guideline(2007)Endocarditis guideline(2007)• ConclusionsConclusions ﾑﾑ The major changes in the updated recommendationsThe major changes in the updated recommendations include the include the

following: (1) The Committee concluded that onlyfollowing: (1) The Committee concluded that only an extremely small number of cases an extremely small number of cases of infective endocarditisof infective endocarditis might be prevented by antibiotic prophylaxis for dental might be prevented by antibiotic prophylaxis for dental proceduresprocedures even if such prophylactic therapy were 100% effective. (2) Infectiveeven if such prophylactic therapy were 100% effective. (2) Infective

endocarditis prophylaxis for dental procedures is reasonableendocarditis prophylaxis for dental procedures is reasonable only for patients with only for patients with underlying cardiac conditions associatedunderlying cardiac conditions associated with the highest risk of adverse outcome with the highest risk of adverse outcome from infective endocarditis.from infective endocarditis. (3) For patients with these underlying cardiac conditions, (3) For patients with these underlying cardiac conditions, prophylaxisprophylaxis is reasonable for all dental procedures that involve manipulationis reasonable for all dental procedures that involve manipulation of of gingival tissue or the periapical region of teeth or perforationgingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) of the oral mucosa. (4) Prophylaxis is not recommended basedProphylaxis is not recommended based solely on an increased lifetime risk of solely on an increased lifetime risk of acquisition of infectiveacquisition of infective endocarditis. (5) Administration of antibiotics solely to preventendocarditis. (5) Administration of antibiotics solely to prevent

endocarditis is not recommended for patients who undergo a genitourinaryendocarditis is not recommended for patients who undergo a genitourinary or or gastrointestinal tract procedure. These changes are intendedgastrointestinal tract procedure. These changes are intended to define more clearly to define more clearly when infective endocarditis prophylaxiswhen infective endocarditis prophylaxis is or is not recommended and to provide more is or is not recommended and to provide more uniform and consistentuniform and consistent global recommendations.global recommendations.

• Table 5. Regimens for a Dental Procedure Situation Agent Regimen: Single Table 5. Regimens for a Dental Procedure Situation Agent Regimen: Single Dose 30 to 60 min Before Procedure Dose 30 to 60 min Before Procedure

• Adults Children Adults Children • Oral Amoxicillin 2 g 50 mg/kg Unable to Oral Amoxicillin 2 g 50 mg/kg Unable to

take oral medicationtake oral medication• Ampicillin 2 g IM or IV 50 mg/kg IM or IV Ampicillin 2 g IM or IV 50 mg/kg IM or IV

Cefazolin or ceftriaxone 1g IM or IV 50 mg/kg IM or IV Cefazolin or ceftriaxone 1g IM or IV 50 mg/kg IM or IV

• Allergic to penicillins or ampicillinAllergic to penicillins or ampicillin ﾑﾑ ooral Cephalexin*  OR Clindamycin OR ral Cephalexin*  OR Clindamycin OR Azithromycin or clarithromycin 2 g 600 mg 500 mg 50 mg/kg 20 mg/kg 15 Azithromycin or clarithromycin 2 g 600 mg 500 mg 50 mg/kg 20 mg/kg 15 mg/kg Allergic to penicillins or ampicillin and unable to take oral medication mg/kg Allergic to penicillins or ampicillin and unable to take oral medication Cefazolin or ceftriaxone  OR Clindamycin 1 g IM or IV 600 mg IM or IV 50 Cefazolin or ceftriaxone  OR Clindamycin 1 g IM or IV 600 mg IM or IV 50 mg/kg IM or IV 20 mg/kg IM or IV IM indicates intramuscular; IV, intravenous. mg/kg IM or IV 20 mg/kg IM or IV IM indicates intramuscular; IV, intravenous. *Or other first- or second-generation oral cephalosporin in equivalent adult or *Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.  Cephalosporins should not be used in an individual with a pediatric dosage.  Cephalosporins should not be used in an individual with a

history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Angina pectoris … stress and anxiety, MI,Angina pectoris … stress and anxiety, MI, sudden death … nitroglycerin sudden death … nitroglycerin

• Myocardial infarction … arrest, congestiMyocardial infarction … arrest, congestive heart failure, bleeding for anticoagulave heart failure, bleeding for anticoagulant, pacemaker cause infective endocardint, pacemaker cause infective endocarditis , >6month saver, morning, short visit, tis , >6month saver, morning, short visit, diazapam for stress, anticoagulant causdiazapam for stress, anticoagulant cause bleeding, no electric if pacemakere bleeding, no electric if pacemaker

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Arrythmia … stress, cardiac arrest, paceArrythmia … stress, cardiac arrest, pacemaker /no electricmaker /no electric

• Congestive heart failure … bleeding for tCongestive heart failure … bleeding for thrombosis in vessels, CVA, short of breathrombosis in vessels, CVA, short of breath, h,

• AIDS … infection, bleedingAIDS … infection, bleeding• DM … infection, poor wound healing , avDM … infection, poor wound healing , av

oid hypoglycemiaoid hypoglycemia

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Hyperthyroidism … thyroid storm, avoid Hyperthyroidism … thyroid storm, avoid epinephrineepinephrine

• Hypothyroidism … hypothyroid coma , sHypothyroidism … hypothyroid coma , sensitive to narcotic, tranquilizerensitive to narcotic, tranquilizer

• Anaphylaxis … vital sign , epinephrine (BAnaphylaxis … vital sign , epinephrine (Bosmin) to tongueosmin) to tongue

• Leukemia … infection, bleeding, delayeLeukemia … infection, bleeding, delayed healingd healing

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Radiation … mucositis , xerostomia , loss of taRadiation … mucositis , xerostomia , loss of taste, constricture of muscle , infection ( candidste, constricture of muscle , infection ( candida) sensitive of teeth , cervical caries , osteoneca) sensitive of teeth , cervical caries , osteonecrosis , trismusrosis , trismus

• Chemotherapy … bleeding for bone marrow sChemotherapy … bleeding for bone marrow suppression , infection , anemia , leukopeniauppression , infection , anemia , leukopenia

• Osteoporosis…Foxamax…BRONJ(bisphosphoOsteoporosis…Foxamax…BRONJ(bisphosphonte related osteonecrosis of jaws)nte related osteonecrosis of jaws)

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) …upright position , avoid bilater(COPD) …upright position , avoid bilateral mandibular or palatal block, avoid rual mandibular or palatal block, avoid rubber dam , low flow O2 , sedation with Nbber dam , low flow O2 , sedation with N2O+O2, if use steroid need supplementa2O+O2, if use steroid need supplementationtion

• Osteoarthritis … aspirin cause bleedingOsteoarthritis … aspirin cause bleeding

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Hypertension … hypertension crisis, CVA,Hypertension … hypertension crisis, CVA, use 1:100000 epi , less than 3 cartridges use 1:100000 epi , less than 3 cartridges

• Asthma … avoid precipitating factors, brAsthma … avoid precipitating factors, bring inhaler, avoid aspirin, narcotic, NSAIing inhaler, avoid aspirin, narcotic, NSAID, erythromycin (if take theophyllin) avoD, erythromycin (if take theophyllin) avoid sulfite-containing local , recent steroiid sulfite-containing local , recent steroid need supplementation , stress freed need supplementation , stress free

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• HBV …contracted by dentist from HBV …contracted by dentist from infectious patient, most carrier are infectious patient, most carrier are undetectable by history, all patients undetectable by history, all patients should be treated with strict aseptic should be treated with strict aseptic approachapproach

• Alcoholic liver disease … bleeding Alcoholic liver disease … bleeding tendenciestendencies

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Hemodialysis … bleeding , hypertension Hemodialysis … bleeding , hypertension , anemia , nephrotoxic drugs , AV shunt i, anemia , nephrotoxic drugs , AV shunt infection ,hepatitisnfection ,hepatitis

• Renal transplant …steoid, infection due Renal transplant …steoid, infection due to immunosuppressiveto immunosuppressive

• Pregnancy and lactation … radiation , drPregnancy and lactation … radiation , drug, stress harm to fetus, supine hypotenug, stress harm to fetus, supine hypotension , drug transmit by breastsion , drug transmit by breast

Considerations of systemic Considerations of systemic disease in OMFSdisease in OMFS

• Rheumatoid arthritis (RA) … bleeding foRheumatoid arthritis (RA) … bleeding for aspirin and NSAID ,steroid usager aspirin and NSAID ,steroid usage

• Stroke … aspirin , coumarin cause bleedStroke … aspirin , coumarin cause bleeding , short appointment, check BP , miniing , short appointment, check BP , minimum epi. Avoid epi. Cordmum epi. Avoid epi. Cord

• Adrenal insufficiency … stress, delayed Adrenal insufficiency … stress, delayed healing , infection , hypertension healing , infection , hypertension

•Thank for your attention