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8/6/2019 Hypertension & Renal
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HYPERTENSION ANDHYPERTENSION AND
RENAL DISEASERENAL DISEASEText ReadingText Reading
Assignment:Assignment:
Essentials of OralEssentials of Oral
MedicineMedicine
Chapter 4Chapter 4 -- pp. 36pp. 36--
4141
Renal DiseasesRenal Diseases
and Hypertensionand Hypertension
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HYPERTENSION (HTN)HYPERTENSION (HTN)
Things to know / ask:Things to know / ask:
What is hypertension?What is hypertension?
How is it diagnosed?How is it diagnosed?
What are signs, symtoms and complications ofWhat are signs, symtoms and complications of
the disease?the disease?
How is the disease treated?How is the disease treated?
What areWhat are side effects of treatmentside effects of treatment??
What are the dental implications of HTN?What are the dental implications of HTN?
What is the relationship withWhat is the relationship with renal diseaserenal disease??
What are the dental implications of renalWhat are the dental implications of renal
disease?disease?
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What is Hypertension?What is Hypertension?
Pathologic Disregulation of Blood PressurePathologic Disregulation of Blood Pressure (Blood(Blood
Volume, Vasoconstriction, or Cardiac Output)Volume, Vasoconstriction, or Cardiac Output)
SustainedSustained
DamagingDamaging
> 140/90 mm Hg> 140/90 mm Hg
Primary (90%)Primary (90%) andand Secondary (10%)Secondary (10%) (Especially Renal(Especially Renal
Associated)Associated) TypesTypes
May Affect 20May Affect 20--40 % ofPopulation40 % ofPopulation
Definition DependentDefinition Dependent % Increases with Age% Increases with Age
More Common in Blacks and MenMore Common in Blacks and Men
Associated with Stress, Weight, Smoking, DiabetesAssociated with Stress, Weight, Smoking, Diabetes
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Blood PressureBlood Pressure
Determining F
actorsDe
termining F
actors
BPBP
Cardiac Output:Cardiac Output:
Stroke VolumeStroke Volume
Heart RateHeart Rate
Force of ContractionForce of Contraction
PeripheralPeripheral
Resistance **Resistance **
Blood Volume **Blood Volume **
DiureticsDiuretics
Beta BlockersBeta Blockers
Calcium ChannelCalcium Channel
BlockersBlockers
VasodilatorsVasodilators
ACE InhibitorsACE Inhibitors
ACE InhibitorsACE Inhibitors
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Types of HypertensionTypes of Hypertension
0
20
40
60
80
100
ssential
Sec
onda
ry
90%
10%RenalRenal
Ischemia ReninIschemia Renin
AdrenalAdrenal
CorticalCorticalCushings SyndromeCushings Syndrome
Aldosterone AdenomaAldosterone Adenoma
MedullaryMedullary
PheochromocytomaPheochromocytoma
PituitaryPituitary
ACTH AdenomaACTH Adenoma
Secondary HTN ClassificationSecondary HTN Classification
Malignant HypertensionMalignant Hypertension
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How is HypertensionHow is Hypertension
Dia
gnosed?Dia
gnosed? Medical DiagnosisMedical Diagnosis
BPBP =/>=/> 140140/90/90 (Systolic/(Systolic/DiastolicDiastolic))
Dental Screening / MonitoringDental Screening / Monitoring
ScreenScreen all Patients for Evidence of Diseaseall Patients for Evidence of Disease
ReferReferKnowns and Unknowns forKnowns and Unknowns for
pressures ofpressures of~~ 140/90140/90 or greateror greater( 2 successive( 2 successive
measurements)measurements)
MonitorMonitorKnown HTN Patients for ControlKnown HTN Patients for Control
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A Relatively RecentA Relatively Recent
Complete ClassificationComplete Classification
OptimalOptimal < 120< 120 < 80< 80
NormalNormal < 130< 130 < 85< 85
High NormalHigh Normal 130130--139139 8585--8989
HTNHTN -- Stage IStage I 140*140*--159159 90*90*--9999
HTNHTN -- Stage IIStage II 160*160*--179179 100*100*--109*109*
HNTHNT -- Stage IIIStage III 180*180*--209209 110110--119119
HTNHTN -- Stage IVStage IV =/> 210=/> 210 =/> 120=/> 120
SystolicSystolic DiastolicDiastolicCategoryCategory
* Routine Care OK but Refer for Diagnosis or Improved Managment* Routine Care OK but Refer for Diagnosis or Improved Managment
*** No* No ElectiveElective TreatmentTreatment withouwithout Medicalt Medical ConsultConsult andand ImprovedImproved BPBP
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WhatareWhatare SymptomsSymptoms andand
ComplicationsComplications of Untreated orof Untreated or
Undiagnosed Disease?Undiagnosed Disease? SymptomsSymptoms
Usually AsymptomaticUsually Asymptomatic (95%)(95%) Unless SevereUnless Severe
Severe:Severe: Dizzines, Ringing in Ears, Headaches, Fainting Spells,Dizzines, Ringing in Ears, Headaches, Fainting Spells,
Blurred Vision, Epistaxis (Bleeding Nose) or otherP
rolongedBlurred Vision, Epistaxis (Bleeding Nose) or otherP
rolongedBleedingBleeding
ComplicationsComplications -- Undiagnosed or UntreatedUndiagnosed or Untreated
Accelerated AtherosclerosisAccelerated Atherosclerosis
Increased Risk ofIncreased Risk ofMyocardial Infarction (M / Heart AttackI)Myocardial Infarction (M / Heart AttackI) andand
Cerobrovascular Accidents (CVA / Stroke)Cerobrovascular Accidents (CVA / Stroke) Congestive Heart Failure (CHF)Congestive Heart Failure (CHF)
Swollen AnklesSwollen Ankles
Shortness of BreathShortness of Breath
CoughCough
Small Risk of Eye and/or Renal DamageSmall Risk of Eye and/or Renal Damage
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How is the DiseaseHow is the Disease
Treated?Treated? Life Style ChangesLife Style Changes
Low Salt DietLow Salt Diet
Weight LossWeight Loss
Reduced StressReduced Stress
Smoking CessationSmoking Cessation
Medication !!!Medication !!!
DiureticsDiuretics (Decrease blood volume)(Decrease blood volume)
VasodilatorsVasodilators (Decrease peripheral resistance)(Decrease peripheral resistance)
Beta Blockers and Calcium Channel BlockersBeta Blockers and Calcium Channel Blockers (Decrease(DecreaseCardiac Output)Cardiac Output)
AAngiotensinngiotensin CConvertingonverting EEnzymenzyme (ACE)(ACE) InhibitorsInhibitors
(Decrease Angiotensin Formation: Decreased(Decrease Angiotensin Formation: Decreased
Vasoconstriction and Blood VolumeVasoconstriction and Blood Volume--AldosteroneAldosterone
associated sodium retention and blood volume)associated sodium retention and blood volume)
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Whatare Side Effects ofWhatare Side Effects of
Treat
ment
of HTNTreat
ment
of HTN?? ExamplesExamples -- SystemicSystemic
Postural Hypotension (Stand upPostural Hypotension (Stand up -- Fall Down)Fall Down)
ImpotenceImpotence
ExamplesExamples -- OralOral
Dry Mouth (Xerostomia)Dry Mouth (Xerostomia)
Gingival Hyperplasia (Calcium ChannelGingival Hyperplasia (Calcium Channel
BlockersBlockers -- NifedipineNifedipine))
Specific Medication DependentSpecific Medication Dependent -- AlwaysAlways
CheckCheck
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Questions to Ask in the Medical HistoryQuestions to Ask in the Medical History
How long diagnosed?How long diagnosed?
What medications taking? / Do you takeWhat medications taking? / Do you take
them? / Any recent changes?them? / Any recent changes?
Any side effects of medications?Any side effects of medications?
How well controlled?How well controlled?
What is normal with and withoutWhat is normal with and without
medication?medication? Any blood pressure related dentalAny blood pressure related dental
problems?problems?
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Things to Do in the Dental ChairThings to Do in the Dental Chair
Ask if patient took medication todayAsk if patient took medication today
Check blood pressure before startingCheck blood pressure before starting
appointmentappointment
Monitor Blood pressure during appointmentMonitor Blood pressure during appointment
Be judicious with vasoconstrictor in anestheticBe judicious with vasoconstrictor in anesthetic
-- Dont use retraction cord with epinephrineDont use retraction cord with epinephrine
Remain alert for medication side effects andRemain alert for medication side effects and
disease complicationsdisease complications
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Pertinent Aspects of MedicalPertinent Aspects of Medical
History Related to HTNHistory Related to HTN
II Have you ExperiencedII Have you Experienced (Symptoms)(Symptoms)??
Chest Pain(Angina)Chest Pain(Angina) -- AtherosclerosisAtherosclerosis
Swollen AnklesSwollen Ankles -- Long StandingLong Standing CHFCHF
Shortness of BreathShortness of Breath -- Long StandingLong Standing CHFCHF CoughCough -- Long StandingLong Standing CHFCHF
Bleeding ProblemsBleeding Problems -- Severe HTNSevere HTN
Dizziness, Ringing in Ears, Headaches, FaintingDizziness, Ringing in Ears, Headaches, Fainting
Spells, Blurred VisionSpells, Blurred Vision -- Severe HTNSevere HTN Excessive Thirst, Frequent Urination /Excessive Thirst, Frequent Urination / DiabetesDiabetes
MellitusMellitus related HTNrelated HTN -- ((AtherosclerosisAtherosclerosis and/orand/orRenalRenal
DiseaseDisease))
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Pertinent Aspects of MedicalPertinent Aspects of Medical
History Related to HTNHistory Related to HTN
III. Have you Had / Do you HaveIII. Have you Had / Do you Have
(Diseases)(Diseases)?? Heart Disease, Heart AttackHeart Disease, Heart Attack
Stroke, Hardening of the ArteriesStroke, Hardening of the Arteries
High Blood PressureHigh Blood Pressure Kidney DiseaseKidney Disease
Diabetes MellitusDiabetes Mellitus
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Pertinent Aspects of MedicalPertinent Aspects of Medical
History Related to HTNHistory Related to HTN
Are You Taking (Medications)?Are You Taking (Medications)?
Any Medications for Blood PressureAny Medications for Blood Pressure
ControlControl
Which Ones?Which Ones?
Check for any side effectsCheck for any side effects
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Management of HypertensiveManagement of Hypertensive
Pat
ient
sPat
ient
s 140/90 orLess140/90 orLess -- No Precautions NeededNo Precautions Needed
141/91141/91 -- 160/110160/110 -- Sedation? Or DelaySedation? Or Delay
> 161/111> 161/111 -- No Elective / Emergency onlyNo Elective / Emergency onlywith Med Consultwith Med Consult
Controlled HTN: LA Vasoconstrictor OK /Controlled HTN: LA Vasoconstrictor OK /
Avoid EpiAvoid Epi--Retraction CordRetraction Cord Undiagnosed Screening: Retake BP /Undiagnosed Screening: Retake BP /
Refer for DiagnosisRefer for Diagnosis
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What is Renal (Kidney)What is Renal (Kidney)
Disease?Disease? Inflammatory / Infectious Disease (Usually) that Damages Kidney andInflammatory / Infectious Disease (Usually) that Damages Kidney and
Alters Kidney FunctionAlters Kidney Function
GlomerulonephritisGlomerulonephritis:: Immunopathic Disease of GlomerulusImmunopathic Disease of Glomerulus (Many Sub(Many Sub--
Types)Types)
PyelonephritisPyelonephritis:: Infection of Connective Tissue and TubulesInfection of Connective Tissue and Tubules
May Require:May Require:
MedicationMedication
DialysisDialysis (End(End--StageStage -- Renal Failure) (300,000)Renal Failure) (300,000)
TransplantTransplant (End(End--StageStage -- Renal Failure) (30,000/yr)Renal Failure) (30,000/yr)
May interfere with:May interfere with:
Drug MetabolismDrug Metabolism
Infection Control and Wound HealingInfection Control and Wound Healing BleedingBleeding (Platelet Adhesion Inhibition)(Platelet Adhesion Inhibition)
Renal Failure May also be Associated with:Renal Failure May also be Associated with:
AnemiaAnemia (loss of erythropoietin)(loss of erythropoietin)
HTNHTN
Secondary HyperparathyroidismSecondary Hyperparathyroidism (loss of Ca++) **(loss of Ca++) **
Uremic Stomatitis ** or Oral CandidiasisUremic Stomatitis ** or Oral Candidiasis
KidneyKidneyDamageDamage
End Stage RenalEnd Stage Renal
Dialysis or TransplantDialysis or Transplant
Glomerulonephritis
Kidney Stones
Developmental
Malformations
Chemical Toxins
Pyelonephritis
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SecondarySecondary
Hyperparath
yroidism **Hyperparath
yroidism **
Decreased Serum CalciumDecreased Serum Calcium
Increased ParathormoneIncreased Parathormone
Calcium removed from boneCalcium removed from bone
Ground Glass Radiographic AppearanceGround Glass Radiographic Appearance
or Radiolucent lesions Filled with Giant Cellor Radiolucent lesions Filled with Giant CellGranulomaGranuloma
Loss ofLamina DuraLoss ofLamina Dura
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Uremic StomatitisUremic Stomatitis
Precedes Renal FailurePrecedes Renal Failure
Ammonia in SalivaAmmonia in Saliva
Oral UlcerationOral Ulceration
Dysgeusia (abnormal taste): metalicDysgeusia (abnormal taste): metalic
Increased SalivationIncreased Salivation
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The KidneyThe Kidney
GlomerulonephritisPyelonephritis
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GlomerulonephritisGlomerulonephritis
-- Immunopathic DiseaseImmunopathic Disease --
d d
Podocyte Epithelial Cells of Bowmans Capsule with foot processes
Endothelial Cells of Glomerular Capillaries
Antigen / Antibody Complexes Localized
orDeposited in Basement Membrane Area
Basement Membrane Area
Inflammatory Damage to Glomerulus
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What is Relationship ofWhat is Relationship of
Renal Disease to HTN?Renal Disease to HTN? Renal Disease may damage the kidney blood supply andRenal Disease may damage the kidney blood supply and
activate theactivate the RENINRENIN--ANGIOTENSINANGIOTENSIN system (Release ofsystem (Release of
ReninRenin with ultimate formation ofwith ultimate formation ofAngiotensin IIAngiotensin II which raiseswhich raises
BP via vasoconstriction and sodium retention)BP via vasoconstriction and sodium retention) -- A form ofA form ofsecondary hypertensionsecondary hypertension
HTN may damage the blood supply to the kidney (viaHTN may damage the blood supply to the kidney (via
accelerated atherosclerosis or arteriolosclerosis) andaccelerated atherosclerosis or arteriolosclerosis) and
further contribute to its own progressionfurther contribute to its own progression
Altered function may increase Na+ and fluid retention withAltered function may increase Na+ and fluid retention withincreased blood volume and pressureincreased blood volume and pressure
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ReninRenin -- AngiotensinAngiotensin
Juxtaglomerular
Cells
Glomerulus and Bowmans Capsule
Decreased BP
Renin Release
Formation ofAngiotensin
Increased Vasoconstriction
Increased Aldosterone
with Increased Na++ and
Fluid Retention
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Kidney Disease / EndKidney Disease / End--StageStage
Renal DiseaseRenal Disease
May Lead to or Cause:May Lead to or Cause:11.. Nephritic SyndromeNephritic Syndrome
Blood in Urine (Hematuria),Blood in Urine (Hematuria),
Nitrogen RetentionNitrogen Retention
(Azotemia) and decreased(Azotemia) and decreased
urine output (oliguria)urine output (oliguria)
22.. Nephrotic SyndromeNephrotic Syndrome
Proteinuria andProteinuria and
Hypoproteinemia withHypoproteinemia with
Edema (Tissue Swelling)Edema (Tissue Swelling)
33.. UremiaUremia
Decreased Filtration(GFR)Decreased Filtration(GFR)
and Toxic Elevated Bloodand Toxic Elevated Blood
Urea Nitrogen (BUN)Urea Nitrogen (BUN)
KidneyKidneyDamageDamage
End Stage RenalEnd Stage Renal
Dialysis or TransplantDialysis or Transplant
Glomerulonephritis
Kidney Stones
Developmental
Malformations
Chemical Toxins
Pyelonephritis
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Renal (Kidney) DiseaseRenal (Kidney) Disease
Questions to AskQuestions to Ask
What kind of kidney problem?What kind of kidney problem?
Does it interfere with everyday living?Does it interfere with everyday living? WhatWhat MedicationsMedications ??
Are you onAre you on DialysisDialysis??
Have you had a KidneyHave you had a Kidney TransplantTransplant??
Do you also haveDo you also have HTNHTN??
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Dental Management ofDental Management of
Patients with Renal DiseasePatients with Renal Disease
AvoidAvoid Renal Toxic DrugsRenal Toxic Drugs (Acetominophen)(Acetominophen)
Alter Dosage or Type ofAlter Dosage or Type ofRenal Excretable DrugsRenal Excretable Drugs
(Penicillin)(Penicillin) DayDay afterafterDialysisDialysis for Dental Appointmentsfor Dental Appointments
Best Mental Status and General HealthBest Mental Status and General Health
Anticoagulants(Post)Anticoagulants(Post) andand Decreased Platelete Function /Decreased Platelete Function /
AdhesionAdhesion (Pre)(Pre) May Interfere with HemostasisMay Interfere with Hemostasis
Increased Risk of Infection forIncreased Risk of Infection forTransplantTransplant
Patients (Patients (ImmunosuppressionImmunosuppression))
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HYPERTENSION / RENALHYPERTENSION / RENAL
Health History FindingsHealth History Findings
Go ToGo To
HealthHealth
HistoryHistory
HEA
TH HI TORYUn i
rsit
f t
P
cific Sc
l
f
ntistr
P
ti
nt N
: S
c. S
c. N
.:
irt
t
:
I.
IRC
EA
RO
RIATEANSWER (l
l
nk if
!
"
not!
nderst
nd q!
estion) :
#
. Yes No Is our$
ener
l
ealt
$
ood ?2. Yes No Has t
ere%
eena c
ange in our
ealt
& it
in t
e last ear?
'
. Yes No Have
ou % een os ( italizedor ada serious illness in t e last t ree
ears?If Y
)
S,&
?0
. Yes No Are ou%
eing treated%
a(
siciannow ? Forwhat?
ateof last
edical exam?
ateof last
ental exam 5. Yes No Have ouhad
(
roblems with(
riordental treatmen t?
1
. Yes No Are
ou in ( ainnow?
II. HAVEYOUEX
ERIENCED:7. Yes No Chest
(
ain (angi na)? #
8. Yes No Dizziness?8. Yes No Swollenankles? # 9. Yes No Ringing inears?9. Yes No Shortness ofbreath? 20. Yes No Headaches?
#
0. Yes No Recent weight loss, fever, night swea ts? 2#
. Yes No Fainting s(
ells?
# #
. Yes No Persistent cough, coughingupblood? 22. Yes No Blurredvision?
#
2. Yes No Bleedingproblems, bruisingeasil
? 2'
. Yes No Seizures?
#'
. Yes No Sinus problems? 20
. Yes No Excessive thirst? #
0
. Yes No Difficult
swallowing? 25. Yes No Frequent urination?
#
5. Yes No Diarrhea, constipation, blood in stools? 21
. Yes No Dr mou th? #
1
. Yes No Frequen t vom iting, nausea? 27. Yes No Jaundice?
#
7. Yes No Difficult
urinating, blood inurine? 28. Yes No Joint pain, stiffness?
III. DOYOUHAVEORHAVEYOUHAD:29. Yes No Heart disease?
0
0. Yes No AIDS
'
0. Yes No Heart attack, heart defects? 0
#
. Yes No Tumors, cancer?
'
#
. Yes No Heart murmurs? 0
2. Yes No Arthritis, rheumatism?
'
2. Yes No Rheumatic fever? 0 '
. Yes No Eyediseases?
' '
. Yes No Stroke, hardeningofarteries? 0 0
. Yes No Skindiseases?
' 0
. Yes No Highblood pressure? 0
5. Yes No Anem ia?
'
5. Yes No Asthma , TB, emphysema , other lungdiseases? 0 1
. Yes No VD (syph ilis orgonorrhea)?
' 1
. Yes No Hepatitis, other liverdisease? 0
7. Yes No Herpes?
'
7. Yes No Stomachproblems, ulcers? 0
8. Yes No Kidney, bladderdisease?
'
8. Yes No Allergies to: drug s, foods, med ications, latex? 0
9. Yes No Thyroid, adrenal disease?
'
9. Yes No Fam ilyhistoryofdiabetes, heart problems, tumors? 50. Yes No Diabetes?
IV. DO YOUHAVEORHAVEYOUHAD:5
#
. Yes No Psychiatric care? 51
. Yes No Hospitalization?52. Yes No Radiation treatments? 57. Yes No Blood transfusions?5
'
. Yes No Chemotherapy? 58. Yes No Surgeries?5
0
. Yes No Prosthetic heart valve? 59. Yes No Pacemaker?55. Yes No Artificial
2
oint? 1
0. Yes No Contact lenses?
V. AREYOUTAKING:
1
#
. Yes No Recreationa l drugs? 1 '
. Yes No Tobacco inany form?
1
2. Yes No Drugs, med ications, over-the-countermed icines1 0
. Yes No Alcohol?(includingAspirin), nat ural remedies?
Please list:
VI. WOMENON
Y:
1
5. Yes No Areyou or couldyou bepregnant ornursing? 1 1
. Yes No Takingbirth control pills?
VII. A
PATIENTS:
1
7. Yes No Doyou haveorhaveyou hadanyotherdiseases ormed ical problems N3
T listedon this form?If so, pleaseexp lain:
To the best of my k nowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my healthand/or medication.
Patients signature: Date:
RECA4 4
REVIEW:
5
. Patients signature Date:
2. Patients signa ture Date:
6
. Patients signature Date:
General Health
Signs & Symptoms
Specific Diseases
Types of Treatment
Medications
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HYPERTENSION / RENALHYPERTENSION / RENAL
UOP Protoc
ol
sUOP Protoc
ol
s
Go ToGo To
UOPUOP
ProtocolProtocol
University of the acific chool of Den tistry
rotocols for the
DENTAL MANAGEMENT OF MEDICALLYCOMPLEX PATIENTS
TOP IC PAG E
1. Bleeding Problems (including anticoagulants) 2
2. Cardiac Problems (heart murmurs, cardiac defects) 4
3. CardiovascularProblems (high blood pressure, arrhythmias) 8
4. Central Nervous System Problems (seizures, stroke) 12
5. Diabetes 15
6. Immunosuppression 17
7 . I n fe cti ou s D is ea se s (tu be rc ul os is , h ep ati ti s, H IV , h er pe s, f lu ) 1 9
8. Kidney Problems 24
9. LiverProblems 25
10. Pregnancy 27
11. Prosthetic Joints 29
7
rotocols compiled by:7
eter L. Jacobsen,7
h.D., D.D.8
Department of7
athology and Medicine
7
lease direct all comments, edits and suggestions to him at:
[email protected] or call (41 9 )@ A @
-66 B@
or fax (41 9 )@ A @
-66 9 4 or write to:Department of 7 athology and Medicine
UO 7 8
chool of DentistryA
19 9
Webster8
treet8
an C rancisco, CA@
411 9
See:See:
Questions to AskQuestions to Ask
Diagnostic TestsDiagnostic Tests
Dental ManagementDental Management
AlertsAlerts
(Complications)(Complications)
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THE ENDTHE END