Clinical Management of Complex Cases in Dentistry: Case of Hypertension With Asthma Essay

Abstract

Medically complicated cases come to routine dental surgery for various procedures. While many of these patients are dealt with successfully, some of these patients may suffer from extreme anxiety. Reducing this anxiety is essential for proper execution of the various procedures. Conscious sedation is one of the most commonly employed methods to relieve anxiety and is now widely gaining acceptance as a safe method for reducing anxiety.

The introduction of various forms of sedation dentistry has made it possible to treat many of the patients who may not be cooperative otherwise. Among the various techniques, the most commonly used these days is the conscious sedation method, most commonly used in pediatric dentistry as well as in anxious adults. Conscious sedation has many forms of administration, and usually it is through clinical knowledge and experience that the dentist may choose a particular one regarding a particular patient.

Ideally a patient who is fit to receive any form of anesthesia is either Class I or a Class II patient. Class I patients comprise normal healthy patients, who are not suffering from any kind of medical condition or disorder. Class II patients, are those who suffer from mild systemic conditions such as well-controlled diabetes or epilepsy, or mild asthma and controlled hypertension. With proper history and medical information, it is possible to conduct various forms of anesthesia with good success in such patients.

The requisite is to have good controlled conditions of the diseases.[1] Even type III patients can be given various forms of anesthetic depending on the individual history, but here more experience is of benefit. Understanding the role of various drug interactions and the effect of various drugs on the medical conditions of the patients is of valuable assistance.

However, as mentioned, there are many cases of patients who may not be in optimal condition for receiving anesthesia. Many medical conditions may require careful medical evaluation before the patient can be considered fit for conscious sedation. A proper medical history and knowledge of any previous medically significant events are essential before carrying out any form of anesthesia.

Consider a case of a patient who is hypertensive as well as asthmatic and is in need of an extraction of the mandibular second molar. Such a patient is also suffering from extreme anxiety, and normal anxiety remission protocols have been considered inadequate for his case. The option comes to the adoption of conscious sedation method. Such a case is not an unusual presentation, and every dentist may be presented with it. The question arises is that how do we determine the correct method of sedation for the patient, and what do we need to consider.

Understanding the patient’s medical history and the severity of his or her condition is the first step that will lead to good diagnosing, clinical decision and successful management. Therefore, the first and foremost is to understand what is the relevance of asthma and hypertension in dental context, and how these conditions can affect the treatment planning.

Asthma is a chronic inflammatory condition of the lungs, which presents as reversible airway obstruction, airway inflammation and increased bronchial hyperresponsiveness.[2] Asthma can be of intrinsic or extrinsic nature, and causes airway obstruction by smooth muscle contraction, inflammation and edema and mucous production. [3]

The asthmatic attacks may be mild, moderate or severe. This is perhaps the main determinant of the condition of the patient, and how dental management will take place. There are many possible causes of an asthmatic attack in a patient. These possible causes increase the risk assessment of the patient, and it is important to clarify them during history taking from the patient. Many of the cases may not even have an asthmatic attack, but sometimes, even the mild cases of asthma may get one during the dental procedure.[4]

Prophylactic measures of preventing asthma attacks include beta 2 antagonists. H1 blocking antihistamines are also considered good methods for the prevention of asthma attack. Promethazine and diphenhydramine are antiasthmatic, antiemetic and sedative all in one, and therefore a very suitable choice for such patients. [5] thiopental and morphine are contraindicated in asthma as they may cause bronchospasm.[6]

The management of the patient, therefore, is dictated by his or her asthma condition. If the patient is anxious, the cause of anxiety is alleviated through counseling and reassurance. Patients are advised to bring their asthma medications during every dental procedure, as a precaution. In many cases, a bronchodilator can be administered before starting treatment. Treatment must not be continued during an asthmatic attack, and proper management procedures must be undertaken to relieve asthma.

Supine position is among the triggers of an asthma attack, therefore, sitting the patient upright may help in relieving it. Mostly in such cases, salbutamol is given, supplemented by oxygen should the condition not improve. Hydrocortisone, as well as prednisolone, can also be used.[7] Since many of the patients may be using chronic steroid therapy, their defense mechanism may not be optimal, and therefore, it is ideal that an antibiotic cover is given to such patients.[8]

Hypertension is the second feature of the supposed patient. While controlled hypertension is not a contraindication for conscious sedation, nevertheless, hypertension can occur during it. Among the various conscious sedation methods, the use of nitrous oxide-oxygen is considered the best in the treatment of hypertensive patients. Nitrous oxide has been shown to improve the homeostatic mechanisms of the body. Although slight changes in the blood pressure and heart rate do take place, the technique is relatively safe. Nitrous oxide effects are essentially dose-related. Nitrous oxide is also seen to increase oxygen tension are therefore is considered as a good technique for hypertensive patients.[9]

Patients with severe hypertension or poorly controlled hypertension are not ideal candidates for conscious sedation.[10] An important point in this regard is that hypertensive drugs enhance the effects of sedatives. Therefore, a proper protocol would require a small dose followed by studying responses, and increasing the doses according to the need. Oxygen mask application is necessary to prevent MI, stroke, renal failure, congestive heart failure or lung edema.

During the sedation, it is necessary to record arterial blood pressure continuously. Even ASA IV patients are not contraindicated for sedation dentistry, provided the treatment is carried out under hospital settings with experienced staff and equipment at disposal. Most of the patients may suffer from orthostatic hypotension after the conscious sedation wears off, therefore, patients must be allowed sufficient time before they are allowed to leave the dental chair. Due to the enhanced effects of sedatives, the inhalational and the intravenous routes can be considered as the best options for such cases.[11]

The IV route of conscious sedation is among the commonly used routines in the adult patients. IV sedation can be used in combination with inhalation or oral sedation as well. This method was first introduced when pentobarbital, meperidine and scopolamine were administered intravenously, and were shown to have sedative and analgesic effects for three or more hours.[12] Proper titration of the dose is necessary for the individual patient, according to his or her particular history. The most common drug used in IV is midazolam, whose dose must be determined by studying the individual patient, and maintaining the IV line until the culmination of the treatment.[13] Other most commonly used agents include benzodiazepines, ultra short-acting barbiturates, antisialogogues either alone or in varying combinations.[14]

Propofol is another drug that has been used as IV sedation in children. It has been demonstrated that a mean dose of 2.5mg/kg given to children was successful in conscious sedation in children for operative dentistry procedures.[15]

Midazolam has shown good efficacy in achieving amnesia and anxiety reduction in patients. Midazolam administered with fentanyl following is the second common procedure that gives better results than midazolam alone, albeit transient respiratory depression. If both these drugs are administered along with methohexital, a deep sedation is achieved. However, oxygen saturation and respiratory rates do decrease transiently, therefore, must not be used in asthmatic patients, or if necessary, must be done with great caution.[16]

Intravenous sedation however, requires a thorough clinical checkup for the health of the patient. The blood pressure is among the most important findings to be kept in mind when opting a patient for this method of induction.

Among the various intravenous drugs, secobarbital has been found to depress the respiratory center and therefore may not be a very good option in an asthmatic patient. Promethazine is known to cause a significant respiratory depression along with orthostatic hypotension. Ativan has been found to have no significant effect on the respiratory or the cardiovascular system, and is therefore considered a very good option.[17]

The Treatment Plan For a Hypertensive and Asthmatic Patient With Anxiety

Considering the evidence, a patient with hypertension and asthma and who suffers from anxiety is most likely to benefit from the midazolam intravenous conscious sedation. Benzodiazepines may also be a good option in such cases. But before carrying it out, a thorough medical and dental history with complete knowledge of medications being used should be taken from the patient. After a thorough evaluation the best mode of conscious sedation method should be used.

The patient should be given a beta 2 antagonist as prophylaxis. The procedure should be ideally carried out at a time when the risk of asthma attacks and peak hypertension levels is not expected. Usually this time is in the afternoon or late mornings. IV dosing of midazolam or any other appropriate drug will be calculated by the specialist based on the patient’s age, gender, health status, presence of any conditions such as asthma etc.

However, since at rapid dosage, midazolam also carries a risk for apnea, the dosage must be given slowly, and with proper titration, with constant monitoring. Midazolam initially is given in 1-2 mg dosing, followed by titrating and maintenance dosage of 0.5-2 mg q 5. Mostly the onset of the drug is within two to three minutes with peak time at 3-5 minutes. If diazepam is given, there must be a slow infusion rate of 5-10 mg, followed by titration of 2 mg q 5 minutes. The patient must be given an oxygen mask to maintain perfusion. Mostly, to help ease the process, inhalation sedation is given followed by IV infusion of the drug.

However, sedatives and opioids must be avoided in such patients due to risk of respiratory depression.[18] The drug must be properly titrated and continuously infused, with constant monitoring of the patient’s vital signs. There should also be a constant monitoring of the arterial blood pressure due to the hypertensive nature of the patient. Some time should be given to the patient after the procedure to adjust, and there should be a proper manner of delivery of the patient to home. With these considerations in mind, the chances of an uneventful procedure are maximized.

References

G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.

Conscious Sedation. A Referral Guide for Dental Practitioners. Dental Sedation Teachers Group. Web.

Conscious Sedation in Dentistry. Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Program, 2006. Web.

Paul Coulthard, Keith Horner, Philip Sloan and Elizabeth Theaker. Master Dentistry. Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, vol 1. Churchil Livingston.

Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.

Hosey M T, Makin A, Jones R M, Gilchrist F, Carruthers M, 2004. Propofol Intravenous Conscious Sedation for Anxious Children in a Specialist Paediatric Dentistry Unit. International Journal of Paediatric Dentistry, Vol 14,no. 1, pp 2-8.

Dominic Lu, Winston I Lu, 2006. Practical Oral Sedation in Dentistry. Part I: Pre-Sedation Consideration and Preparation. Compendium of Continuing Education in Dentistry. Web.

Lopez-Jimenez J, Gimenez-Prats MJ. Sedation in The Geriatric Patient. MED ORAL 2004;9:45-55.

Managing Maladaptive Behaviors: The Use of Dental Sedation for Persons with Disabilities. Southern Association of Institutional Dentists. Web.

Managing Medically Complex Patients. Web.

Procedural Sedation Provider Module for Adult Patients, 2001. Web.

Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston Derek M Steinbacher and Micheal Glick, 2001. The Dental Patient with Asthma. An Update on Oral Health Considerations. JADA Vol 132, PP 1229-1239.

1. Conscious Sedation. A Referral Guide for Dental Practitioners. Dental Sedation Teachers Group. Web.
2. Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
3. Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment., Churchil Livingston.
4. Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
5. Derek M Steinbacher and Micheal Glick, 2001. The Dental Patient with Asthma. An Update on Oral Health Considerations. JADA Vol 132, PP 1229-1239.
6. G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.
7. Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
8. Managing Medically Complex Patients. Web.
9. G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.
10. Paul Coulthard, Keith Horner, Philip Sloan and Elizabeth Theaker. Master Dentistry. Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, vol 1. Churchil Livingston.
11. LÓPEZ-JIMÉNEZ J, GIMÉNEZ-PRATS MJ. SEDATION IN THE GERIATRIC PATIENT. MED ORAL 2004;9:45-55.
12. Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
13. Conscious Sedation in Dentistry. Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Program, 2006. Web.
14. Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
15. Hosey M T, Makin A, Jones R M, Gilchrist F, Carruthers M, 2004. Propofol Intravenous Conscious Sedation for Anxious Children in a Specialist Paediatric Dentistry Unit. International Journal of Paediatric Dentistry, Vol 14,no. 1, pp 2-8.
16. Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
17. Managing Maladaptive Behaviors: The Use of Dental Sedation for Persons with Disabilities. Southern Association of Institutional Dentists. Web.
18. Procedural Sedation Provider Module for Adult Patients, 2001. Web.