Preoperative Health Status Evaluation
General Anxiety Reduction Protocol
• Hypnotic agent to promote sleep on night before
• Sedative agent to decrease anxiety on morning of
• Morning appointment and schedule so that reception
room time is minimized
Nonpharmacologic means of anxiety control:
• Frequent verbal reassurances
• Distracting conversation
• No surprises (clinician warns patient before doing
anything that could cause anxiety)
• No unnecessary noise
• Surgical instruments out of patient’s sight
• Relaxing background music
Pharmacologic means of anxiety control:
I!I Local anesthetics of sufficient intensity and duration
I!! Nitrous oxide
II Intravenous anxiolytics
• Succinct instructions for postoperative care
• Patient information on expected postsurgical sequelae
(e.g., swelling or minor oozing of blood)
II! Further reassUrance
II Effective analgesics
II Patient information on who can be contacted if any
• Telephone call to patient at home during evening
after surgery to check if any problems exist
Management of Patient with History of Angina Pectoris
1. Consult patient’s physician.
2. Use anxiety reduction protocol. ,
3. Have nitroglycerin tablets or spray readily available.
Use nitroglycerin premedication if.indicated.
4. Administer supplemental oxygen.
5. Ensure profound local anesthesia before starting
6. Consider use of nitrous oxide sedation.
7. Monitorvital signs closely.
8. Possible limitation of amount of epinephrine used
(O.O!4 mg maximum).
9. Maintain verbal contact with patient throughout procedure to monitor status
control in patients with ischemic heart disease should be considered. A fresh bottle .of nitroglycerin tablets or a canister of nitroglycerin spray should be nearby for use if necessary (Box 1-10).
Myocandial infection MI occurs when ischemia (resulting from an oxygen demand and supply mismatch) causes cellular dysfunction and death, The infarcted area of myocardium becomes nonfunctional and eventually
necrotic and is surrounded by an area of usually reversibly ischemic myocardium that is prone to serve as a nidus for dysrhythrnias. During the early hours and weeks after an MI, treatment consists of limiting myocardial work requirements, increasing myocardial oxygen suppressing, and suppressing the production of dysrhythmias by irritable foci in ischemic tissue. In addition, if any of the primary conduction pathways arc involved in the infarction, pacemaker insertion may be necessarv, If the patient survives the early weeks after an MI, the variably sized necrotic area is gradually replaced with scar tissue, which is unable either to contract or properly conduct electrical signals.
The management of an oral surgical problem in a patient who has had an Ml begins with a consultation with the patient’s physician. Generally, it is recommended that elective major surgical procedures be deferred until at least 6 months after an infarction. This delay is based on statistical evidence that the risk of infarction after an MI drops to as low as it will ever be by about 6 months, particularly if the patient is properly supervised medically. The advent of thrombolytic-based treatment
strategies and improved post-MI care make an automatic 6-month wait to do dental work unnecessary. Straightforward oral surgical procedures typically performed in the dental office may be performed less than 6 months after an MI if the. procedure is unlikely to provoke significant
anxiety and the -patient had an uneventful recovery from the-MI. In addition, other dental procedures may proceed if cleared by the patient’s physician via a medical consult.
Patients with a history of MI should be carefully questioned concerning their cardiovascular health. An attempt to elicit evidence of undiagnosed dysrhythmias or congestive heart failure (hypertrophic cardiomyopathy)
should be made. Some patients who have had an MI take aspirin or other anticoagulants to decrease coronary thrombogenesis; this information should be sought because it can affect surgical decision making.
If more than 6 months have elapsed or physician clearance is obtained, the management of the patient who has had an MI is similar to care of the patient with angina, An anxiety reduction program should be used.
Supplemental oxygen can also be considered. Prophylactic nitroglycerin should be -used only if directed by the patient’s primary care physician, but it should be readily available. Local anesthetics containing epinephrine are
safe to use if given in proper amounts using an aspiration technique. Vital signs should be monitored through out the peroperative period (Box 1-11).
Coronary artery bypass grafting. In general, with respect to major oral surgical care, patients who have had coronary artery bypass grafting (CABG) are treated in a, manner similar to patients who have had an MI. Before major elective surgery is performed, 6 months are allowed
to elapse. If major surgery is necessary before-e months alter the CABG, the patient’s physician should be consulted. Patients who have had CABG usually have a his.