Surgery lec 1

Dr.Yanal Nusair
‫بسم الله الحمن الرحيم‬

1st of all I wanna say that it is my 1st lec ,, 2aal 7toni bel 2wl mshaan "
tkon el lec sahleh …ok bs el lec elle ana 7derta kant ktir a2sar mn
hek ,,,soooo I think eno yaqeen de7ko 3lai o 3toni lec ’3er elle
<<7derta!!! Just kidding 6b3n.had akeed el dr. hoe elle b7ki bsor3a
r7 tla7zo eno shkl el saf7at ktir b5wef !!!! bs 5odoha mnni el m7dra
!!!!! kolha 7ki fadi so enjoy it y3niii e8r2 w estmte3
.u will see that all info. Are repeated from previous years
So, elle mshtaaaa2 mnkom lal systems mmken bbsa6a yrage3 la wraa2
!!!!!!!!!!!!!!!!!!!!!!! CVS o ma ydros hadi el lec asln
" ?Bs plzz eza 8rrto t8r2oha 5leha b Ramadan OK

Today is the 1st lec. in a series of lecs. About how to

manage medically compromised patients in the dental
.clinic .it is the 1st of 3 lecs. In this field
But before that I will take few mins !!! talking about
something else as an introduction to clinical dentistry
.in general
U have just started clinical dentistry, u started
dealing with human beings, with patients (pts), NO
.FANTOM HEAD ANY MORE

:NOW
.there is a pt behind every tooth **
???Why do we say that
Bcoz with time our spectrum & horizon tends to
become narrower & narrower , if u remember u
started ur 1st yr with general subjects ,then subjects
become more specialized with human body then with
the oral cavity, and am afraid if we keep on going like
this, by the end pf the 5th yr u will b thinking only of
.the TOOTH!! ,which is not appropriate
It is the pt who come with a dental problem(prob), it
.is not the tooth. We treat pts. & don’t treat teeth
Let we say it in a different way: it doesn’t help if u
successfully restored a tooth & cause the pt a bigger
!!prob. with his heart

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Dr.Yanal Nusair
??U didn’t solve the prob. like that RIGHT
So,,, keep in mind that there is a pt behind every
.tooth, keep focusing on the bigger pic

Having said that, a diabetic pt is dealt with & treated

in a slightly different way from a non-diabetic pt ,or if
the pt has a prob. with his heart valves, or if he is on
steroids there are certain precautions that should b
.taken to treat him
.If the pt is hypertensive the same thing applies
Plus,,, we modify our treatment plan according to the
pt general health status, u will not b able to
appropriately modify ur treatment plan if u don’t
. know the pt MH
U will not know that ur pt is diabetic or allergic to
(penicillin if u don’t ask him about that→(MH
If u don’t ask him ,and prescribed penicillin then the
pt takes it home and he developed anaphylactic
.shock, then it is ur responsibility
It is not an excuse to say " I did not know that the pt
" is allergic to penicillin
There are different ways of obtaining a MH , it doesn’t
matter how to obtain it as long as it is thorough and
.comprehensive
ONE simple way to remember how to take a detailed
:MH is this one
Anemia, Bleeding disorders, Cardiorespiratory
diseases, Drug treatment …. If u notice we started
with A,B,C,D,……..etc
This is just one way u can do it , I don’t mind if u do it
in a completely different way as long as it is detailed
.and thorough

U have a legal and ethical obligation toward ur pt ,

the methods and techniques u use to treat ur pt

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Dr.Yanal Nusair
should be up to date , we go back to what we started
.with , THERE IS A PTN. BEHIND EVERY TOOTH

Then the Dr. put a pic. Of a face and the msg that he
wants us to take is that a superficial look can be
. misleading , u can miss lots of the details

When u examine ur pt , take a deep look , don’t be

mislead by what the pt says …. Pt may come to u
saying " my tooth hurts me plz take it out " … u
examined him and find a remaining root at that area,
and when u extract it the pt came back the next day
with the same prob. ( this is caused by u being
(mislead by ur pt
ALWAYS obtain ur own history , ur own clinical
findings , ur own diagnosis, and make sure that u
have a correct diagnosis before u formulate ur
. treatment plan

( A CLINICAL EXAMPLE: slide NO. ( 7

Now this pt came to ur clinic complaining of a small
numb on his gingiva, clinically we know that this is a
sinus tract draining pus into the oral cavity, when u
see this u expect an infection around one of the roots.
It is not clearly shown in this pic. But this tooth which
is the 1st or 2nd premolar "I don’t know" as the Dr. said
, is grossly carious , there is only a thin buccal shell, &
.nothing behind it

So, What we do next is to take a radiograph: slide no

. ((8
U see in the radiograph that the tooth is grossly
carious & around the apex of the root , there is a
radiolucency which suggest a periapical infection ,
. now u go ahead and do a root filling for the tooth
Yes, the tooth is indicated for RCT but will this solve
?the problem

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Dr.Yanal Nusair
If u look carefully at the radiograph , u notice that
. there is something abnormal that can b easily missed
NOW , a simple test is to insert a gutta percha cone
into this tract: slide no (9) ( it is not painful , the pt
( doesn’t even feel it
Gutta percha is radiopaque →then take another
radiograph: slide no (10) , and this will lead u to the
source of infection which is not the tooth we were
.thinking of few mins ago
. SO, DON’T B MISLEAD BY UR Pt

U will not kill the pt if u treated the wrong tooth but,

.u will not b dealing with the pt main complaint

NOW, we will move to our main topic ! (y3ni kol elle

(ra7 kan 7ki fadi

MEDICALLY COMPROMISED PATIENTS

:We will start with

(Cardio-vascular Diseases 1 (CVD1

:(heart failure (HF-1
CENTRAL failure in the circulation . failure of the
. heart to supply the circulation with its demands

Note

heart failure(HF)

Is the end result of a variety of conditions, not all of them are

cardiovascular. Basically the heart is unable to meet the circulatory
needs of the body.

** right HF:dependent oedema & venous engorgement are prominent.

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Dr.Yanal Nusair
** left HF:beathlessness is the principal sign

There is ever present risk of precipitating HF,even in treated patients,

by increased heart demands eg. Fluid overload or excessive exertion.

2- cardiac arrest : sudden cessation of heart beats .

3- shock : A PERIPHERAL failure ( circulation is not

supplied with its demands due to a problem at the
periphery caused by wipes of vasodilatation .

4- ischemia : reduced blood supply to a tissue or

organ

THESE TERMS ARE IMPORTANT as the Dr. said

Not all pt in the clinic will tell u that they have HF or

IHD or etc…., so how do u know ???

By knowing signs and symptoms of cardiac

diseases .So, always ask ur pt about signs and
symptoms , suspect the disease , then u can refer the
pt to his physician before u start treatment .

Keeping in mind that a good number of cardiac pts

are asymptomatic not bcoz they have no symptoms
but bcoz most of the symptoms are controlled by their
medications.

So, if ur pt is asymptomatic then u may know that he

has a cardiac disease by asking him about the
medications he is taking.

** BREATHLESSNESS or shortness of breath is a very

common sign of HF , in the more advanced cases the
pt starts to develop what we call ORTHOPNEA in

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Dr.Yanal Nusair
which the pt cannot lie flat on his back, if he did so,
he becomes breathless.

So, u can ask the pt : how many pillows u put under ur

head when u go to bed ?!

If the pt doesn’t rest until he puts 3 or 4 pillows , then

there will b a question about his heart condition .

**CHEST PAIN is a common symptom of angina or IHD

** PALPITATIONS: arrythmias.

** CYANOSIS: HF( u can see it in the lips when they

become bluish )

**CHANGES IN BP : hypertention( HT)

** FINGER CLUBBING & SPLENTAL HEMORRHAGE: u

get them with different cardiac conditions so they are
not specific.

NOW, how do we classify cardiac diseases??

1- ORGAniC: structural defect in the heart,

something wrong with myo,endo,or peri cardium.
2- Functional : the structure is intact or normal
but the function is abnormal. The most clear
example of functional disorder is HT &
arrythmias .

Hypertensive pts who don’t have any complications

, if u examine their heart or BVs u will not b able to
differentiate them from those of normal pts .

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Dr.Yanal Nusair
The Dr. said that he may skip some of the details
coz we don’t need them .

The most important to know about HF is the main

signs and symptoms , and the most important 2 are
breathlessness( patient comes to the clinic gasping
for air ) and oedema ( ankle oedema ) especially
with congestive HF.

Also u can see pitting oedema in their feet ( if u

press, u can create a depression in the skin at that
area )

Other signs include cyanosis , fatigue (pt looks ill ),

distinction of the neck veins ( which is not easy so
forget about it ).

HOW TO MANAGE HEART DISEASES IN GENERAL ?

- 1st line of treatment is diuretics → they get

overload of fluids so, diuretics get rid of this
excess fluids from the limbs
- Digoxin or digitoxin to strengthen the heart
beats so they improve the heart function.

From a dental point of view there are things u

should keep in mind:

- the most imp. one : those patients are poor

risk for GA , u may decide to take ur pt to the
operating room to take an impression for eg.

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Dr.Yanal Nusair
To give GA for a pt to take an impression !!!!!!!!!!!!
yes, it happens.

Or, in case of severe gag reflex, this is an extreme

case .

But u may come across a pt who needs multiple

surgical procedures in different quadrants of the
mouth .

Eg. A pt has 4 impacted wisdoms that all of them

need to b extracted,& the pt Is anxious, then there
is a choice to send him to the operating room and
extract them all in one session . BUT, if the pt gave
a history of HF , then u cannot do that.

** supine position is better avoided in those pts to

avoid breathlessnss….. use indirect vision instead .

** avoid stress , but it is not true , u cannot avoid

stress, but u can minimize it by : EXPLAINING to
the pts what u r doing , not to surprise them, to
explain what to expect .

Eg. U give a pt a local anesthetic injection for

extraction and u told him that the tooth will become
totally numb and he will not feel any thing , this is
completely wrong, coz under local anesthesia he
will not feel pain of extraction but he will feel the
vibration, movement , pressure . so, if u don’t
explain u will put the pt under more stress .

- be gentle with ur pt , short appointment and

short treatment sessions , and if the pt is
extremely anxious u can give diazepam for eg. Or
u can sedate him IV .

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Dr.Yanal Nusair
SO, KEEP STRESS TO THE MINIMUM .

HYPERTENTION,HT(‫)ارتفاع ضغط الدم‬

PERSISTENTLY INCREASED BP due to something
wrong with the peripheral resistance ( BVs ) and not
the heart itself .

As the Dr. said 90% of cases are of unkown cause

( essential ) , the remaining 10 % are due to other
causes like: renal disease or hormonal imbalance
.(( secondary

Note

Hypertension(HT)

Consistently raised Blood pressure ( <160 systolic,< 90 diastolic ,< 3

months ) and is a risk factor for IHD ,CVA (cerebrovascular
accidents),and renal failure.Up to 95% has no definable cause (essential
HT) ,& 5% is 2ndary to another disease such renal dysfunction or
endocrine disorders.

Signs & symptoms:

It is asymptomatic in the vast majority of cases

unless the pt developed complications. But it has a
sign which is increased BP when u measure it .

Symptoms: something the pt feels but u cannot

detect.

Signs: something u can see weather the pt feels or

not.

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Dr.Yanal Nusair
Now, long term HT , causes multiple complications ,
some of them are acute. The 2 most serious acute
complications are:

1- cardiac arrest.
2- CVA (cerebro-vascular-accident)

These complications usually follow SUDDEN,

SIGNIFICANT increase in BP .And this could happen in
a dental clinic .

for eg. A HT pt with BP of 140/90 comes to extract his

tooth,u give him LA but it doesn’t make adeep
profound action 4 some reasons, then u put ur forceps
& start moving the tooth, then the pt starts
screaming.

So if u don’t stop treatment ,BP may shoot suddenly

from 140/90 to 250/120 .

This sudden increase in BP can cause cardiac arrest.

Or rupture of small vessel inside the cranium and
cause CVA .

NotE(FROM OXFORD FOR CLINICAL DENTISTRY)

Dental implications for pts with CVD

To prevent the risk of pricipitating HF or MI in pts with compromised

CVS,,,

• avoid GA ,especially within 6 months of an MI.

• adequate LA with sedation when necessary.
• Avoid excessive loads of adrenaline.
• Consider drug interactions and remember some of these pts
are anticoagulated.

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Dr.Yanal Nusair
B3deen en6rdna mn el hall l2n 2aal m7jooz la nas
tanyeen!!!!!!!!

O beni o benko mnee7 elle sar hek l2n t3bt mn el7ki

…..

The end

For the next surgery lec which will b the last one in
Ramadan , we will meet here @ 11:30 – 12:30 & and
after Ramadan we go back to 12:30

BDKO T7YAT ??? YLLA…

THE BIGGEST ONE IS 4 MY SIS. NOOR (walla t3bet aktr mni bel lec) ,o kman MANAR (m3
enk ma t3bti), & for MY LOVELY FRNDS:

YASMINITA (MISS U SOOOO MUCH),,RUBA (3la 2sas bdk tsa3deni !! wella el23deh b via
via 2ham?? Beni o benk 2ham bkteer ),HEBA (MY frnd & partner kmaan!!!! Sho hal7az
tb3i….3asal bdonk no way)

RAWAN( jayeeki el door) , ZAIN (weank???),& ESRA2 ’3ZLAN (LOVE U )

F6ooM AS3D ( barbie, LOVE U SO MUCH)

O A7LA t7yeh La superman 3njd ktir 3m yt3b !!!!!!!

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Dr.Yanal Nusair
BTW I don’t think there is any mistake …..

O kol sana o ento salmeen

Maram batiha

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