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

1. 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

2. Considerations of systemic disease in OMFS 林聰勝

3. Considerations of systemic disease in OMFS • Rheumatic fever and rheumatic heart disease …infective endocarditis (2g PC) • Congenital heart disease … infective endocarditis , prolong bleeding time(thrombosis in small vessels) • Surgical corrected cardiovascular lesions …anticoagulant prolong bleeding time , endocarditis

4. Considerations of systemic disease in OMFS • Artificial heart valves …anticoagulant prolong bleeding time , endocarditis • Premedication : amoxicillin 2g , child 50mg/kg • Heart transplant : suppression of immune, anticoagulant, high steroid , may need supplementation

5. AHA Prevention of Infective Endocarditis guideline(2007) • Conclusionsﾑ The major changes in the updated recommendationsinclude the following: (1) The Committee concluded that onlyan extremely small number of cases of infective endocarditismight be prevented by antibiotic prophylaxis for dental procedureseven if such prophylactic therapy were 100% effective. (2) Infectiveendocarditis prophylaxis for dental procedures is reasonableonly for patients with underlying cardiac conditions associatedwith the highest risk of adverse outcome from infective endocarditis.(3) For patients with these underlying cardiac conditions, prophylaxisis reasonable for all dental procedures that involve manipulationof gingival tissue or the periapical region of teeth or perforationof the oral mucosa. (4) Prophylaxis is not recommended basedsolely on an increased lifetime risk of acquisition of infectiveendocarditis. (5) Administration of antibiotics solely to preventendocarditis is not recommended for patients who undergo a genitourinaryor gastrointestinal tract procedure. These changes are intendedto define more clearly when infective endocarditis prophylaxisis or is not recommended and to provide more uniform and consistentglobal recommendations.

6. Table 5. Regimens for a Dental Procedure Situation Agent Regimen: Single Dose 30 to 60 min Before Procedure • Adults Children • Oral Amoxicillin 2 g 50 mg/kg Unable to take oral medication • 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 • Allergic to penicillins or ampicillinﾑoral Cephalexin* OR Clindamycin OR 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 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. *Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage. Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

7. Considerations of systemic disease in OMFS • Angina pectoris … stress and anxiety, MI, sudden death … nitroglycerin • Myocardial infarction … arrest, congestive heart failure, bleeding for anticoagulant, pacemaker cause infective endocarditis , >6month saver, morning, short visit, diazapam for stress, anticoagulant cause bleeding, no electric if pacemaker

8. Considerations of systemic disease in OMFS • Arrythmia … stress, cardiac arrest, pacemaker /no electric • Congestive heart failure … bleeding for thrombosis in vessels, CVA, short of breath, • AIDS … infection, bleeding • DM … infection, poor wound healing , avoid hypoglycemia

9. Considerations of systemic disease in OMFS • Hyperthyroidism … thyroid storm, avoid epinephrine • Hypothyroidism … hypothyroid coma , sensitive to narcotic, tranquilizer • Anaphylaxis … vital sign , epinephrine (Bosmin) to tongue • Leukemia … infection, bleeding, delayed healing

10. Considerations of systemic disease in OMFS • Radiation … mucositis , xerostomia , loss of taste, constricture of muscle , infection ( candida) sensitive of teeth , cervical caries , osteonecrosis , trismus • Chemotherapy … bleeding for bone marrow suppression , infection , anemia , leukopenia • Osteoporosis…Foxamax…BRONJ(bisphosphonte related osteonecrosis of jaws)

11. Considerations of systemic disease in OMFS • Chronic obstructive pulmonary disease (COPD) …upright position , avoid bilateral mandibular or palatal block, avoid rubber dam , low flow O2 , sedation with N2O+O2, if use steroid need supplementation • Osteoarthritis … aspirin cause bleeding

12. Considerations of systemic disease in OMFS • Hypertension … hypertension crisis, CVA, use 1:100000 epi , less than 3 cartridges • Asthma … avoid precipitating factors, bring inhaler, avoid aspirin, narcotic, NSAID, erythromycin (if take theophyllin) avoid sulfite-containing local , recent steroid need supplementation , stress free

13. Considerations of systemic disease in OMFS • HBV …contracted by dentist from infectious patient, most carrier are undetectable by history, all patients should be treated with strict aseptic approach • Alcoholic liver disease … bleeding tendencies

14. Considerations of systemic disease in OMFS • Hemodialysis … bleeding , hypertension , anemia , nephrotoxic drugs , AV shunt infection ,hepatitis • Renal transplant …steoid, infection due to immunosuppressive • Pregnancy and lactation … radiation , drug, stress harm to fetus, supine hypotension , drug transmit by breast

15. Considerations of systemic disease in OMFS • Rheumatoid arthritis (RA) … bleeding for aspirin and NSAID ,steroid usage • Stroke … aspirin , coumarin cause bleeding , short appointment, check BP , minimum epi. Avoid epi. Cord • Adrenal insufficiency … stress, delayed healing , infection , hypertension

16. Thank for your attention